Nurse Care Manager - General Medicine & Geriatrics

Washington University in St. Louis

28d

About The Position

The Nurse Care Manager (NCM) is responsible for providing enhanced care coordination to patients attributed to WashU Medicine value-based care agreements. Primary responsibilities include providing telephonic transitional care outreach to patients recently discharged from an inpatient stay, seen in the ED for potentially avoidable treatments, or those with multiple complex comorbidities. The NCM will complete transitions of care assessments, medication reconciliation, providing disease specific education, and assisting to schedule follow-up appointments to reduce likelihood of readmission and/or avoidable ED use.

Requirements

• B.S.N. - Bachelor Of Science In Nursing
• Basic Life Support - American Heart Association, Basic Life Support - American Red Cross, Registered Nurse - Illinois Department of Financial and Professional Regulation, Registered Nurse - Missouri Division of Professional Registration
• No specific work experience is required for this position.
• Not Applicable
• A driver's license is not required for this position.
• Registered Nurse in the state of Missouri or Illinois.
• Basic Life Support certification (Online BLS certifications, those without a skills assessment component, are not sufficient to meet the BLS requirements).

Nice To Haves

• Adult Health Nursing
• Ambulatory Care
• Clinical Patient Care
• Confidentiality
• Data Analysis
• Delegation Management
• Electronic Medical Record (EMR) Software
• Emergency Training
• Epic EHR
• Leadership
• Managed Care
• Medical Triage
• Nursing Fundamentals
• Oral Communications
• Patient Care Plans
• Patient Management
• Research Management
• Software Platforms
• Strategy Implementation
• Written Communication

Responsibilities

• Care Coordination & Clinical Support Serve as the primary point of contact for medically and socially complex patients and their caregivers.
• Coordinate care across primary care, specialty clinics, home health, rehabilitation facilities, and community partners.
• Facilitate transitions of care (hospital → home, rehab → outpatient, assisted living, long-term care, hospice).
• Monitor chronic disease management (e.g., dementia, frailty, CHF, COPD, diabetes) and identify early signs of decompensation.
• Review and triage incoming clinical messages and calls related to care coordination, patient needs or concerns requiring follow-up.
• Conduct routine check-ins in all clinic locations to support providers, staff, and patients, ensuring timely response to questions and identification of emerging patient needs.
• Patient Assessment & Care Planning Conduct comprehensive geriatric assessments addressing medical, functional, cognitive, psychosocial, and environmental needs.
• Develop individualized care plans in collaboration with providers and the interdisciplinary team, incorporating Age-Friendly Health System principles (What Matters, Medication, Mentation, Mobility).
• Identify gaps in care, medication concerns, fall risks, cognitive decline, and safety risks; escalate appropriately.
• Support patients and caregivers managing chronic conditions by reinforcing care plans, educating on self-management, and helping navigate complex care systems.
• Social Support & Resource Navigation Assess and address social determinants of health impacting older adult outcomes (transportation, caregiving strain, financial barriers, food insecurity, isolation).
• Connect patients and caregivers with community resources, caregiver supports, and state/local services.
• Assist with long-term care planning, home health needs, durable medical equipment, and referrals to senior services or palliative care.
• Advocate for patients and families to ensure access to appropriate services and supports.
• Communication & Collaboration Maintain close communication with providers about patient needs, care barriers, and changes in condition.
• Collaborate with social work, nursing, pharmacy, therapy services, and community agencies.
• Participate in interdisciplinary team meetings, including GAC IDT meetings and case reviews, to discuss complex patients and adjust care strategies.
• Provide guidance and support to caregivers navigating dementia, functional decline, or other patient specific challenges.
• Advocacy & Patient Support Serve as an advocate for patients and families navigating complex medical and social systems.
• Support caregivers managing stress, burnout, and complex care responsibilities.
• Assist with insurance or coverage questions within the scope of nursing practice.
• Documentation & Compliance Document all care coordination activities, assessments, care plans, follow-up calls, and resource referrals in the EMR.
• Track patient progress, outstanding care needs, and follow-up items.
• Ensure communication and follow-up comply with clinic protocols, state requirements, and organizational policies.
• Identify safety concerns (e.g., potential elder abuse or neglect) and escalate per mandatory reporting guidelines.
• Education & Problem-Solving Provide patient and caregiver education on medications, disease processes, self-management strategies, and available resources.
• Independently research resources, troubleshoot barriers to care, and develop patient-centered solutions.
• Support staff education on geriatric-specific issues, social determinants of health, and interdisciplinary care coordination.

Benefits

• Up to 22 days of vacation, 10 recognized holidays, and sick time.
• Competitive health insurance packages with priority appointments and lower copays/coinsurance.
• Take advantage of our free Metro transit U-Pass for eligible employees.
• WashU provides eligible employees with a defined contribution (403(b)) Retirement Savings Plan, which combines employee contributions and university contributions starting at 7%.
• Wellness challenges, annual health screenings, mental health resources, mindfulness programs and courses, employee assistance program (EAP), financial resources, access to dietitians, and more!
• We offer 4 weeks of caregiver leave to bond with your new child.
• Family care resources are also available for your continued childcare needs.
• Need adult care? We’ve got you covered.
• WashU covers the cost of tuition for you and your family, including dependent undergraduate-level college tuition up to 100% at WashU and 40% elsewhere after seven years with us.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level