Care Manager Registered Nurse

Hopscotch Primary Care•Lexington, NC

1d•Hybrid

About The Position

The Care Manager Registered Nurse (CMRN) manages a panel of higher-acuity patients through primarily remote case management and targeted in-clinic support, including High-Risk Huddle meetings. The role is accountable for end-to-end care management, with an emphasis on reducing avoidable admissions and emergency department utilization, improving clinical outcomes and patient experience, and supporting continuity of care across the healthcare continuum. The CMRN partners with providers, clinic staff, and Care Center Managers to deliver coordinated, proactive, patient-centered care. The position is primarily remote, with regular in-office presence based on patient or program needs and a minimum in-office presence of once a month. Hopscotch Primary Care provides primary care tailored to rural communities through a comprehensive care team and a value-based care model. The organization describes its mission as transforming healthcare in rural America and making high-quality healthcare accessible across communities.

Requirements

At least 2 years of experience as a care manager embedded in an interdisciplinary team.
Active registered nurse (RN) license in North Carolina.
BLS certification.
Experience working in a primary care clinic focused on chronic disease management.
Experience with motivational interviewing, behavior change, health promotion, and coaching.
Strong verbal and written communication skills and a customer service orientation.

Nice To Haves

Experience with behavioral health.
Experience with community-based organizations.

Responsibilities

Manage a defined panel of high-risk patients and deliver comprehensive, longitudinal case management.
Develop, implement, and continuously update individualized care plans in collaboration with providers and care teams.
Conduct ongoing telephonic outreach and monitoring to improve patient outcomes.
Coordinate care among patients’ Hopscotch Primary Care providers, specialists, hospitals, emergency departments, skilled nursing facilities, and community resources.
Collaborate with the transitions-of-care team to support smooth transitions and meet patient needs after the transitions-of-care period.
Partner with providers, medical assistants, licensed practical nurses, and Care Center Managers to align on patient care plans and priorities.
Escalate clinical concerns and barriers to care in real time.
Participate in team huddles, case reviews, and interdisciplinary care discussions.
Track and improve quality and utilization metrics tied to patient outcomes.
Maintain in-office presence at least once a month and as needed to support high-risk patient visits and care coordination for complex patients.
Coordinate with in-office LPNs for occasional home visits for high-risk or complex patients when clinically appropriate.
Assess social determinants of health, home safety, and barriers to care.
Coordinate community-based services and resources to support patient care plan goals.
Build trusted relationships with patients, families, and caregivers.
Educate patients on disease management, medications, and care plans.
Use motivational interviewing and coaching techniques to drive behavior change.
Follow care management protocols, regulatory requirements, and documentation standards.
Support continuous improvement of care management workflows and outcomes.
Identify and report gaps, risks, or adverse events.
Contribute to the development of best practices, training, and process improvements.