Care Manager Registered Nurse
About The Position
The Care Manager Registered Nurse (CMRN) is a hybrid role responsible for managing a panel of higher-acuity patients (HPP) through a combination of primarily remote case management and targeted in-clinic support, such as High-Risk Huddle meetings. This role is accountable for end-to-end care management, with a strong focus on reducing avoidable admissions (ADK) and emergency department utilization (EDK), improving clinical outcomes and patient experience, and supporting care continuity across the healthcare continuum. The CMRN partners closely with providers, clinic staff, and Care Center Managers (CCMs) to deliver coordinated, proactive, and patient-centered care. This position is primarily remote, with regular in-office presence based on patient or program needs.
Requirements
- Minimum of 2 years of experience as a care manager embedded into 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
- Strong verbal and written communication skills and customer service orientation
- Patient-first, team-oriented
- Agile and thoughtful in a fast-paced environment
- Solutions-driven, always looking to improve
- Accountable, with high standards for yourself and others
- Hands-on and collaborative across diverse teams
- Clear, concise communicator who follows through
- Positive, assuming good intent
- Customer-focused, with a passion for serving patients and providers
Nice To Haves
- Experience with behavioral health and community-based organizations
- Experience with motivational interviewing, behavior change, health promotion, and coaching
Responsibilities
- Manage a defined panel of high-risk patients, delivering comprehensive, longitudinal case management
- Develop, implement, and continuously update individualized care plans in collaboration with providers and care teams
- Perform ongoing telephonic outreach and monitoring to improve patient outcomes
- Coordinate care across the patients HPC provider, specialists, hospitals, EDs, SNFs, and community resources
- Partner and collaborate with transitions of care team, for a smooth transition and to ensure that the patient needs are met following the transitions of care period
- Partner with providers, MAs, LPNs, 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 minimum of 1 time a month and as needed to support high-risk patient visits and assist with care coordination for complex patients
- Coordinate with in office LPN 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
- Provide education on disease management, medications, and care plans
- Utilize motivational interviewing and coaching techniques to drive behavior change
- Adhere to 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 development of best practices, training, and process improvements
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
