Company Overview:

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 a remote role responsible for reviewing electronic health records to gather pertinent clinical, behavioral health, social, and utilization information needed to build compliant care plans for patients enrolled in a Dual Eligible Special Needs Plan. This position does not include direct patient interaction. The Nurse Care Manager uses clinical judgment, strong documentation standards, and careful review practices to create accurate, complete, and CMS-compliant care plans.

The Nurse Care Manager spends the day reviewing source documentation in internal and external electronic health records, extracting relevant information, and translating that information into high-quality care plans. Completed care plans are uploaded to an external electronic health record and must meet CMS requirements, plan expectations, and internal quality standards.

This role is accountable for completing a minimum of 100 care plans per week while maintaining a high level of accuracy, consistency, and scrutiny. The Nurse Care Manager must be able to identify missing, conflicting, or unclear information in the record and escalate documentation or workflow concerns through the appropriate internal process.

The Nurse Care Manager works independently in a remote environment and manages daily work to meet productivity, quality, and compliance expectations. Team members have flexibility to create their own schedule, but must be available during normal business hours for manager one-on-ones, team meetings, training, quality reviews, and other required collaboration.

The Nurse Care Manager collaborates with managers, quality reviewers, and operational leaders to support timely completion of care plans, resolve documentation questions, and maintain alignment with CMS and D-SNP program requirements.

Skills Required:

• Active unrestricted RN license in the state of California
• Minimum of 3 years of clinical experience, preferably in care management, utilization review, quality review, documentation review, or managed care.
• Strong understanding of care planning, chronic disease management, behavioral health documentation, social needs documentation, and CMS compliance requirements.
• Ability to review electronic health records, identify clinically relevant information, and synthesize findings into a complete care plan.
• Proficiency in electronic health records and care management platforms.
• Excellent written communication skills and strong attention to detail.
• Experience with Medicare Advantage, D-SNP, or CMS-regulated documentation is preferred.
• Ability to complete a minimum of 300 compliant care plans per week.
• Ability to work independently in a remote environment while remaining available during normal business hours for required meetings, manager one-on-ones, training, and team collaboration.

Key Behaviors:

Care Plan Quality:

• Creates accurate, complete, and CMS-compliant care plans based on careful review of available electronic health record documentation.

Collaboration:

• Works effectively with managers, quality reviewers, and operational leaders to resolve documentation questions and support care plan completion goals.

Proactive Communication:

• Communicates timely updates, barriers, and documentation concerns to the appropriate manager or team member.

Compliance and Documentation:

• Applies CMS requirements, plan expectations, and internal standards when building and uploading care plans.

Care Coordination:

• Uses available record information to ensure care plans are organized, complete, and aligned with documented patient needs.

Time Management:

• Manages daily workload, prioritizes records, and meets weekly productivity expectations while maintaining quality standards.

Problem Solving:

• Identifies missing, conflicting, or unclear documentation and escalates concerns through the appropriate internal process.

Confidentiality:

• Maintains patient confidentiality and follows HIPAA regulations when reviewing, documenting, and uploading care plan information.

Remote Accountability:

• Maintains productivity, responsiveness, and meeting availability while working a flexible remote schedule.

Competencies:

Clinical Documentation Review:

• Reviews electronic health record documentation and identifies relevant clinical, behavioral health, social, and utilization information for care plan development.

Effective Communication:

• Documents clearly, accurately, and professionally in care plans and internal communication channels.

Care Plan Development:

• Builds care plans that are complete, individualized based on available documentation, and compliant with CMS and D-SNP plan requirements.

Technology Proficiency:

• Uses internal and external electronic health record systems to review documentation, complete care plans, and upload finalized plans accurately.

Outcome-Oriented:

• Meets productivity expectations while maintaining the quality, accuracy, and compliance required for CMS-regulated care plans.

Independent and Team-Oriented:

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

Critical Thinking:

• Uses clinical judgment to interpret record information, identify documentation gaps, and ensure care plans reflect documented needs and risks.

Multitasking and Prioritization:

• Manages a high-volume workload, prioritizes tasks, and consistently completes required weekly care plan volume.

Quality Focus:

• Maintains strong attention to detail and applies a high level of scrutiny to each care plan before submission.

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.