Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as lengthy delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It is no wonder 98% of patients report being fully satisfied with Upward Health!

Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission. Or you could join us and experience it all for yourself.

WHY IS THIS ROLE CRITICAL?

The Care Team Pod is a multidisciplinary team of licensed and unlicensed staff who provide direct support and care to Upward Health’s patients. The Care Team Pod is comprised of a diverse team that may include medical providers, nurse practitioners, registered nurses, licensed social workers, pharmacists, therapists, and care specialists. The care team works directly within the community in the patients’ homes or agreed upon locations as well as provides services through telehealth. The Nurse Care Manager is a remote role, responsible for the direct telephonic care of assigned high-risk patients requiring a care plan that addresses the patients core chronic conditions with an overall goal of controlling exacerbations of conditions and patient self-management.. This role will demonstrate a commitment to effective and efficient care leading to high-quality outcomes, while managing the total cost of care.

The Nurse Care Manager acts as a liaison between patients, their families, doctors, and ancillary health care providers ensuring the patient, family and caregivers understand the care plan and can progress towards self-care wherever possible. The Nurse Care Manager will serve in a direct care and patient advocacy role and will ensure interdisciplinary care is optimized toward targeted outcomes. By collaborating with the Clinical Operations team to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the patient’s health. The Nurse Care Manager implements transitions of care and disease specific care planning and care coordination efforts to support and guide the patient through their journey within the healthcare ecosystem of providers, hospitals, outpatient services, etc.

The Nurse Care Manager will ensure the safe and effective transition of care for patients discharging from various inpatient sites of care to home – hospital discharges, skilled nursing facility discharges, rehabilitation discharges, etc. Through telephonic-based outreach, the Nurse Care Manager will contact the patient or caregiver within 48 hours of discharge to conduct a comprehensive discharge assessment, conduct medication reconciliation, provide patient or caregiver education, support post-discharge order fulfillment (i.e., Durable Medical Equipment, Home Health Care, etc.), and assess for any potential barriers to a successful transition to home. Additionally, the Nurse Care Manager will confirm the patient has a provider appointment within 7-14 days of discharge, or sooner, depending on the post-discharge needs of the patient.

KEY RESPONSIBILITIES

• Assess, evaluate, and provide for the ongoing monitoring of patient care coordination and delivery that results in optimized quality, clinical and financial outcomes
• Develop a relationship of safety and trust with transparent communication between the patient, caregivers, and care team. Identify, acknowledge, and advocate for the needs of the patient
• Participate with other care team members in regular or special meetings such as clinical rounds
• Monitor daily ADT alerts (ADT: Admit, Discharge, Transfer) for enrolled patient with active care plans. Perform telephonic outreach and patient assessment within 48-hours of discharge and provide patient education, support for treatment regimen adherence, and conduct medication reconciliation & care management to support self-management and independent living
• Identify potential discharge care gaps and communicate through providers as necessary to close gaps in care
• Complete comprehensive assessments and develop patient-centric care plans utilizing clinical expertise to evaluate the patients need for Upward Health and additional services
• Continuously monitor and update care plans and coordinate care across providers
• Educate patients and families about treatment plans and options
• Accurately document and submit medical documentation
• Provide guidance and support to patients and families inclusive of community-based support programs – work with Care Specialists to coordinate connections to community resources, with emphasis on medical, behavioral, and social services
• Evaluate patient outcomes with respect to the medical record, patient and family history and available healthcare utilization information
• Review results from medical tests (lab, imaging, etc.) and ensure visibility across all care providers including escalation of abnormal or out-of-range findings
• Facilitate the coordination of treatment plans of the PCP, specialists, and interdisciplinary team (IDT), communicate patient progress by conducting regular IDT meetings and evaluations (disseminating results and obstacles to the healthcare team and family), and attend IDT and Nursing rounds
• Implement physician orders – ensuring a linkage between all care providers throughout a patient’s episodes of care
• Apply case management standards, maintains HIPAA standards and confidentiality of protected health information, and reports critical incidents and information regarding quality-of-care issues
• Maintain knowledge of diagnoses, signs and symptoms of disease, standard therapy protocols derived from evidence-based outcomes, medications, and warning signs of non-optimal patient outcomes
• Perform other duties as assigned

KNOWLEDGE, SKILLS & ABILITIES

• Interpersonal savvy, with the demonstrated ability to interact with and influence people to establish trust and build strong relationships
• A high sense of urgency and can-do attitude required for a role at a start-up company

• Strong organization skills and ability to manage and maintain a personal schedule
• Ability to establish priorities and meet deadlines
• Ability to work independently within a virtual operating environment and as part of a team

• Excellent oral and written communication skills
• Ability to conduct written and oral instructions
• Ability to exercise judgment in the application of professional services

REQUIRED QUALIFICATIONS

• Unrestricted registered nursing license in the state(s) of care management activities a minimum requirement
• Demonstrated expertise in care management and coordination across all healthcare providers, patient, and caregivers
• Experience with completing real-time documentation in EHR and/or Care Management systems
• Ability to effectively communicate across a multitude of key care partners
• Ability to motivate patients and caregivers to follow care plans and optimize self-care potential
• Excellent documentation skills with the ability to manage multiple patient cases
• Sound critical thinking to assess, analyze and monitor outcomes to recommend the optimal plan of care
• Computer literacy and ability to effectively communicate within the business structure

PREFERRED QUALIFICATIONS

• 3 years of care management experience in an outpatient setting preferred
• 3 years of care transition or care coordination experience preferred
• 3 years in a hospital, health plan, or related healthcare business entity is also considered
• Experience serving Medicare, Medicaid, and Duals population
• Multi-state nursing license
• Proven experience working independently, seeing patients in the community or virtually

Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.