Nurse Care Manager Chronic Disease

Community Health Care•Millville, NJ

About The Position

The LPN Nurse Care Manager provides relationship-centered, evidence-based chronic disease care management to patients with multiple chronic conditions, complex healthcare needs, high comorbidity burdens, or elevated risk of adverse outcomes. The role supports patients in understanding and managing chronic conditions, developing sustainable self-management behaviors, following prescribed treatment plans, and accessing healthcare and community resources. Working with primary care providers, registered nurses, behavioral health professionals, pharmacists, community health workers, specialists, and other interdisciplinary team members, the Nurse Care Manager helps coordinate patient-centered interventions to improve outcomes and engagement, close care gaps, and reduce preventable emergency department visits and hospitalizations. The position focuses on patient education, condition monitoring, behavioral change support, care plan implementation, care transitions, and evaluation of patient progress. Within the scope of practical nursing practice, the LPN uses a structured nursing process to identify changes in health status, reinforce individualized care plans, implement authorized interventions, and communicate findings to the supervising RN or authorized provider.

Requirements

Active license as a Registered Nurse or Practical Nurse; current LPN or RN license in the state of New Jersey.
Minimum of 2 years of experience in chronic care management.
Strong understanding of clinical protocols and evidence-based medicine for chronic conditions.
Understanding of social determinants of health.
Skills in de-escalation, trauma-informed care, data collection, and grant reporting.
Valid driver’s license and clean driving record, required for mobile unit oversight.

Responsibilities

Use electronic health records, population health registries, risk reports, and provider referrals to identify and prioritize patients for chronic care management.
Conduct outreach to explain care management services, assess interest, and support program enrollment.
Review patient histories, conditions, medications, preventive care gaps, utilization, reported concerns, access barriers, functional limitations, and social needs.
Maintain an assigned caseload and prioritize patient engagement based on risk, protocols, and individual needs.
Conduct structured patient interviews and collect clinical, functional, behavioral, and social information within scope and established protocols.
Document symptoms, vital signs, medication adherence concerns, health behaviors, and treatment barriers; identify concerning changes and escalate them to the supervising RN or authorized provider.
Contribute collected findings and patient information to RN- or provider-led assessments and individualized care planning.
Collaborate with patients, caregivers, RNs, providers, and interdisciplinary teams to implement patient-centered care plans and reinforce established goals and treatment recommendations.
Assist patients with realistic self-management goals, monitor progress, document outcomes, and recommend care plan review when circumstances change.
Provide follow-up and chronic disease support for conditions including diabetes, hypertension, cardiovascular disease, heart failure, COPD, asthma, and obesity.
Monitor adherence, symptoms, self-management activities, and home measurements; escalate findings outside established clinical parameters.
Reinforce warning signs and instructions on when to seek urgent or emergency care; facilitate recommended testing, appointments, specialty services, and preventive screenings.
Identify and address chronic disease care gaps and promote proactive condition management.
Build therapeutic relationships and reinforce education about conditions, medications, nutrition, physical activity, symptom monitoring, and preventive care.
Use motivational interviewing, teach-back, goal setting, and trauma-informed communication to support behavior change and patient engagement.
Review patient-reported medication use and medication lists; identify discrepancies, adherence barriers, and concerns for further review.
Reinforce provider and pharmacist instructions, facilitate refill requests and pharmacy communication, connect patients with medication assistance resources, and report medication concerns to prescribers.
Support medication reconciliation workflows after discharge or care transitions, with final clinical review and authorization performed by the appropriate licensed professional.
Identify and engage patients after emergency visits, admissions, discharges, and transitions between care settings; conduct timely post-discharge outreach according to protocols.
Review and reinforce discharge plans, schedule follow-up appointments, identify barriers to medications and services, and communicate unresolved needs or changes in condition.
Coordinate with hospitals, rehabilitation and skilled nursing facilities, specialists, and community organizations to support continuity of care and reduce avoidable utilization.
Serve as a consistent patient contact and coordinate communication, appointments, referrals, diagnostic testing, and preventive services.
Identify social determinants of health and facilitate connections to community health workers, social workers, behavioral health, nutrition, transportation, and other resources.
Advocate for patients facing access barriers and escalate unresolved service barriers or clinically significant concerns.
Support chronic care management and population health programs, including CCM, PCM, APCM, and other approved programs when assigned.
Complete required patient contacts and care coordination activities; document eligible services, dates, activities, duration, and clinical information in accordance with organizational and payer requirements.
Assist with closing HEDIS, UDS, payer-specific, and value-based care gaps; collaborate with Quality and Population Health teams on monitoring and performance measurement.
Participate in case conferences, care management huddles, and quality improvement initiatives; identify recurring barriers and workflow improvement opportunities.
Contribute accurate data to program evaluation, organizational reporting, and grant reporting.
Maintain timely, accurate documentation of encounters, interventions, follow-up, progress, barriers, and escalation activities; track caseload and complete follow-up within established timeframes.
Follow organizational policies, nursing standards, infection prevention and patient safety practices, HIPAA, confidentiality requirements, and applicable healthcare regulations.
Practice within licensure scope and required clinical direction; participate in training, professional development, competency assessments, and quality improvement activities.
Demonstrate professionalism, accountability, compassion, and interdisciplinary collaboration; perform additional related duties as assigned.