Nurse Care Manager (Evergreen)

At Honest Health, we believe in purpose and partnership to lead the transformation in primary care. Our team of healthcare experts and clinicians collaborates with a range of stakeholders—from health systems, physician organizations, and payers to providers, practices, and patients — to deliver innovative solutions that elevate care, control costs, and support long-term health. Guided by our core values, we’re creating a value-driven model that creates lasting benefits for everyone, now and into the future. For us, that's just an Honest day’s work.

You’re a collaborative professional, driven by the potential to make a meaningful impact in healthcare. The challenges of healthcare don’t deter you—instead, you see them as opportunities to find innovative solutions that benefit the partners, people, and communities we serve. Honest Health’s commitment to purpose, innovation, communities, and kindness resonates with you, inspiring you to bring commitment, creativity, and compassion into your work. You’re ready to join a team focused on reimagining primary care for a healthier future that benefits all. Your Role: You will manage patients’ specialized needs based on their individual condition(s) and/or reason for recent utilization in collaboration with physicians, advanced practice providers, and care coordination team members. Your job duties will include taking full ownership of assigned patients with complex chronic conditions, serious illness, advanced frailty, or recent healthcare utilization with the goal of avoiding preventable admissions, reducing unnecessary healthcare use, and optimizing patient outcomes. Through standardized assessments and workflows you will work with the patient to identify needs based on their values, goals and preferences. From this assessment, in partnership with the patient, you will develop an effective, and comprehensive plan of care for each member. Care plans will be used to coordinate patient care delivery with Honest clinicians, network providers, contracted vendors, and community-based services. This work takes place remotely, but you must be licensed in the state or states where the role is based (Michigan and/or New York).

Quickly build empathetic relationships with patients and families. Evaluate and identify patients’ needs based on their respective values, goals, and preferences, then translate these needs into clinical needs. Interface with primary care physicians, advanced practice providers (APP), specialists, and various disciplines on the development of case management plans/programs. In conjunction with the physician/APP, implement care/treatment plans by coordinating access to health services across multiple providers/ disciplines. Refer patients to internal Honest team members for care management activities as outlined by defined procedures. Monitor care and identify cost-effective measures, including recommendations for alternative levels of care and utilization of resources. In partnership with Honest team members, effectively coordinate patient admissions and discharges from hospitals or skilled nursing facilities via coordination with respective facility clinicians and case managers. Build relationships across network hospitals, SNFs, home health companies, and DME vendors within the respective community. Monitor and evaluate the effectiveness of the case management plans based on quality and cost drivers and modify as necessary. Coordinate the interdisciplinary approach to providing continuity of care, including transfer coordination, discharge planning and obtaining all authorizations/approvals/transfers as needed for outside services for patients/families. Act as a patient advocate and educator to assure that the patient has the knowledge to care for his/her condition and patient is educated and empowered to be responsible for participating in the plan of care. Develop individualized patient/family education plan focused on self-management and deliver patient/family education specific to a disease state. Engage internal resources to identify and respond to social determinants of health such as lack of transportation, stable housing, or food resources. Participate in data collection and analysis of clinical outcomes of care and customer satisfaction standards. Participate in the formulation and implementation and monitoring of action strategies and outcomes of care or customer service. Ensure that accurate records are maintained of the care associated with each patient. Actively participate in huddles, interdisciplinary team (IDT) sessions, and patient case conferences. Commendably represents Honest to patients, their families, and the community. Perform other related responsibilities as assigned.