Nurse Care Manager Job at Upward Health, San Francisco, CA

QW9pV3JXaE1BVE9NUnY0cUN4WFR5a3IrOXc9PQ==
  • Upward Health
  • San Francisco, CA

Job Description

:

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

Job Title & Role Description:

The Nurse Care Manager is responsible for comprehensive care coordination for high-risk patients in Contra Costa County. This role focuses on care planning, emergency department (ED) avoidance, and discharge planning for patients transitioning between levels of care. The Nurse Care Manager will work closely with patients, caregivers, health plans, and primary care providers to facilitate seamless care across settings and ensure continuity of services.

This is a hybrid position with the autonomy to visit patients in their homes or at the hospital, as clinically appropriate. Additionally, the Nurse Care Manager will lead interdisciplinary team (IDT) meetings with a clinical focus to align care plans and support patient-centered outcomes.

Skills Required:

  • Active, unrestricted Registered Nursing (RN) license in California

  • Minimum of 3-5 years of case management experience, including care planning and coordination

  • Strong knowledge of POLST, Advance Directives, and end-of-life planning

  • Experience with home health, hospice, and care transitions

  • Proficiency in electronic health record (EHR) systems and digital care management tools

  • Excellent communication and patient education skills

  • Critical thinking and decision-making abilities in complex care management

  • Ability to work independently

  • Experience collaborating with health plans, PCPs, and community resources

Key Behaviors:

Patient-Centered Care:

  • Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow care plans.

Collaboration:

  • Effectively coordinates care with the patient’s health plan, primary care provider, and other care team members to optimize health outcomes.

Proactive Communication:

  • Actively engages patients and caregivers within 48 hours of hospital discharge to assess needs, update care plans, and mitigate potential readmission risks.

Advocacy and Education:

  • Provides clear, compassionate education to patients and families regarding POLST, Advance Directives, and available support services.

Care Coordination:

  • Ensures that care is effectively coordinated across multiple providers and services, particularly during transitions of care.

Time Management:

  • Efficiently manages patient caseloads, balancing multiple tasks while adhering to established deadlines and care plans.

Problem Solving:

  • Identifies potential gaps in care, collaborates with providers to resolve issues, and implements strategies to optimize patient outcomes.

Confidentiality:

  • Maintains patient confidentiality and follows HIPAA regulations in all communications and documentation.

Cultural Competence:

  • Demonstrates respect for diversity, providing culturally sensitive care that meets the needs of diverse patient populations.

Competencies:

Clinical Expertise:

  • Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication:

  • Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development:

  • Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency:

  • Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented:

  • Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented:

  • Able to work independently while also collaborating effectively with a multidisciplinary team.

Critical Thinking:

  • Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization:

  • Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement:

  • Motivates patients to follow care plans and improve self-care skills through regular communication and support.

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.

 

Compensation details: 100000-105000 Yearly Salary

PI144bca8645bf-30492-37537710

Job Tags

Similar Jobs

Wonder Learning Center

Teacher (Middle/High ) Hybrid Microschool Job at Wonder Learning Center

 ...Are you an experienced middle- or high-school teacher who loves teaching, but is frustrated with the current state of education? Are you tired of the bureacracy, teaching to the test, and checking boxes at the expense of real learning? Do you miss the days of seeing students... 

Sycomp

Warehouse Associate Job at Sycomp

Sycomp is looking for a skilled Warehouse Associate to work onsite at our Integration Center in Doral, FL. Duties and Responsibilities Assist in the physical unpacking and racking of server equipment into server cabinets. Ability to rack and cable following a ...

Hays

Procurement Manager - MTA Projects Job at Hays

About the company Our client is a premier provider of Integrated Facilities Management, with their competency being self-delivery of mechanical maintenance and workplace wellness services. At 130 years and growing, they are time-tested industry leaders in all facets of...

ODW Logistics

CDL A Truck Driver (Home Daily) Job at ODW Logistics

 ...Requirements for Local CDL A Drivers: Must have a valid CDL A and Medical Card. Must have 1 year of recent verified CDL A experience. Dist-Trans CO. is the asset-based fleet for ODW Logistics. ODW Logistics is a people-focused and customer-driven third-... 

China Global Connections

图书馆馆长 Curator of Library Job at China Global Connections

 ... 10-15k We are looking for a Curator of Library for an international high school based in Guangzhou, Guangdong province. This is a full-time position starting ASAP...