Upward Health

Manager

• Field-based care coordination of high-risk patients who require comprehensive care plans
• Collaborate with a multidisciplinary Care Team to ensure optimal health outcomes through personalized care plans, self-management, and disease prevention
• Focus on chronic care management and care transitions, particularly for patients discharged from inpatient settings
• In-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem
• Act as an advocate for patients and ensure integration of services across providers, hospitals, and outpatient services
• Conduct in-home and telephonic assessments, develop care plans, and perform medication reconciliations with real-time EHR documentation
• Reach out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care
• Manage multiple patient cases, prioritize tasks, and maintain patient confidentiality following HIPAA regulations
• Use digital tools for care coordination and communication to document, track, and coordinate patient care

Nurse Care Manager