RN Care Manager

Job Title: Care Manager

Position Summary

The Care Manager serves as the primary liaison between patients, their families, and the healthcare team to ensure coordinated, high-quality care. This role focuses on managing the day-to-day implementation of patient care plans, particularly for individuals with chronic or complex medical conditions. The Care Manager supports improved health outcomes by addressing clinical needs, social determinants of health, and patient education.

Key Responsibilities

Care Planning & Assessment

• Conduct comprehensive assessments of patients’ medical history, mental health status, and social needs (e.g., housing, food security).
• Develop and implement individualized care plans in collaboration with providers and care teams.

Care Coordination

• Schedule and coordinate appointments with primary care providers, specialists, and ancillary services.
• Ensure timely communication and information sharing among all members of the healthcare team.

Patient Advocacy & Education

• Educate patients and families on diagnoses, treatment plans, and medication management in an understandable manner.
• Empower patients to actively participate in their care and improve self-management skills.

Monitoring & Follow-Up

• Conduct routine follow-ups (e.g., monthly via phone or telehealth) to monitor patient progress.
• Identify early warning signs of health decline and intervene to prevent hospitalizations or complications.

Resource Coordination

• Connect patients with community resources such as transportation, financial assistance, and social support services.

Administrative Duties

• Document all patient interactions accurately in the Electronic Health Record (EHR).
• Support chronic care management (CCM) billing and compliance requirements.

Qualifications & Requirements

Education

• Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field required.

Licensure/Certification

• Active, unrestricted license as a Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) preferred.

Experience

• Minimum of 2 years of clinical or care coordination experience required.
• Experience in chronic care management or population health preferred.

Skills & Competencies

• Strong interpersonal and communication skills
• High level of empathy and patient-centered approach
• Excellent organizational and time management abilities
• Critical thinking and problem-solving skills
• Ability to manage multiple patients and priorities effectively
• Proficiency with Electronic Health Records (EHR) systems

Work Environment

• Medical office or clinical setting
• Combination of in-person, phone, and telehealth patient interactions
• May involve coordination with external providers and community organizations

Goal of the Role

To improve patient outcomes, enhance care coordination, reduce hospital readmissions, and ensure patients receive comprehensive, efficient, and compassionate care.