About the role:

This is a hybrid role with 75% remote office time and 25% field-based time

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
  • Complete comprehensive assessments and develops care plans utilizing clinical expertise to evaluate the patients need for Upward Health and additional services
  • Develop a relationship of safety and trust with transparent communication between the patient, caregivers, and the care team
  • Identify, acknowledge, and advocate for the needs of the patient  
  • Build a patient-centric care plan and environment that incorporates the needs of the patient  
  • Review the patient diagnoses and facilitate the coordination of treatment plans of the PCP, specialists, and interdisciplinary care team – Attend Interdisciplinary Team (IDT) rounds
  • Evaluate patient outcomes with respect to the medical record, patient and family history and available healthcare utilization information
  • 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
  • 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 
  • Provide guidance and support to patients and families inclusive of community-based support programs
  • Review results from medical tests (lab, imaging, etc.) and ensure visibility across all care providers including escalation of abnormal or out-of-range findings
  • Implement physician orders – ensuring a linkage between all care providers throughout a patient’s episodes of care
  • Communicate patient progress by conducting regular interdisciplinary meetings and evaluations, disseminating results and obstacles to the healthcare team and family
  • Function as a resource for non-clinical staff including first point of contact for patient triage and with escalation to the provider(s) as needed
  • Coordinate community resources, with emphasis on medical, behavioral, and social services 
  • Apply case management standards, maintains HIPAA standards and confidentiality of protected health information, and reports critical incidents and information regarding quality-of-care issues
  • Meet with patients in their homes, worksites, physician’s offices, or hospital to provide management of services
  • Participate with other care team members in regular or special meetings such as Clinical rounds
  • Perform other duties as assigned

Knowledge, Skills and 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
  • Travel to patient’s home, provider’s office, hospitals, etc., required with dependable car; This is a hybrid role with 75% remote office time and 25% field-based time
  • 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 in a hospital, health plan or related healthcare business entity also considered 
  • Experience serving the Medicare, Medicaid, and Duals population
  • Proven experience working independently seeing patients in the community

**We require all our employees to be vaccinated and to show proof of vaccination upon hire**

Apply Here
First Name
Last Name
Email
Phone
Create Password if new user
Upload your resume
Zipcode
State
Occupation
Specialties
By clicking Apply Now, you agree to our Terms and Privacy.
We'll be contacting you regarding your application on the phone number provided.

Note: Your information will never be shared without your permission.
About DirectShifts

We connect clinicians with hospitals directly, bypassing external staffing agencies or recruiters.


Earn more money
Fully transparent
Online Credentialing