RN Care Manager
Core
Coordinate comprehensive primary care for patients with multiple chronic conditions by collaborating with primary care providers and interdisciplinary teams to monitor, track, and deliver patient-centered care.
Role type
Senior RN Care Coordinator (Population Health)
Builds
Care coordination plans, transitional care management, and community resource referrals for chronic disease patients.
Domain
Healthcare / Population Health / Chronic Disease Management
Required skills
RN licensure, population health or care coordination experience, EHR proficiency, patient outreach, care plan development, community resource coordination, telephonic communication, in-person patient visits
Preferred skills
Pediatric experience, Medicaid value-based program experience, patient education and engagement, bilingualism (Spanish)
Technologies
EHR systems
Responsibilities
Review patient non-compliance reports and conduct outreach to ensure timely visits; Provide transitional care management for post-discharge patients; Collaborate with providers to develop and administer care plans for high-risk patients; Identify and coordinate referrals to community resources and disease management programs; Conduct face-to-face visits in offices or communities; Participate in regular care team meetings to discuss patient care.
Seniority
Mid-level, hands-on IC