Upward Health

Manager

• Coordinate care for high-risk patients requiring comprehensive chronic-condition care plans
• Work with a multidisciplinary Care Team to achieve optimal patient health outcomes
• Focus on chronic care management and care transitions, especially after inpatient discharge
• Conduct in-person and telephonic patient outreach and assessments
• Perform medication reconciliation
• Ensure continuity and integration of care across providers, hospitals, and outpatient services
• Advocate for patients and educate patients and caregivers about treatment options and care plans
• Reach out to patients and caregivers within 48 hours of discharge
• Identify gaps in care and resolve issues collaboratively with providers
• Manage multiple patient cases and caseload priorities
• Maintain patient confidentiality and follow HIPAA regulations
• Provide culturally sensitive care to diverse patient populations
• Use clinical judgment to assess patient progress and adapt care plans
• Document, track, and coordinate care using EHR and care management systems

Nurse Care Manager

Supervisor

• Oversee the day-to-day activities of Upward Health's Care Specialists
• Guide a team including medical assistants, certified nursing assistants, community health workers, and peer support specialists
• Supervise and coordinate Care Specialists' work
• Support training efforts and train new staff on protocols
• Ensure care coordination across medical and behavioral providers
• Provide assistance to patients
• Conduct community outreach and represent Upward Health in the community
• Manage caseloads
• Ensure compliance with Upward Health's policies and procedures
• Manage, analyze, and present data to support clinical and operational improvements
• Maintain relationships with local community resources
• Assist the Manager of Care Coordination with leadership duties

Nurse Care Manager

Supervisor, Care Coordination