Nurse Care Manager

JCHCC DBA Inclusivcare•Avondale, LA

About The Position

The Nurse Care Manager ensures patients requiring chronic care management receive timely medical services, comprehensive education, intensive care coordination, and self-management support to improve health outcomes. The role serves as an advocate and point of contact for patients, families, and caregivers, connecting them with resources and community healthcare services. In collaboration with a multidisciplinary care team, the Nurse Care Manager coordinates care throughout the healthcare continuum and acts as a liaison within the organization and with community partners. The position focuses on high-risk and vulnerable patients who may be at risk of health deterioration or poor outcomes, supporting acute, chronic disease, and preventive care across multiple healthcare settings. The role works across the organization and institutes Patient Centered Medical Home (PCMH) principles using clinical protocols and tracking tools under clinical leadership. It indirectly supervises Care Coordinators and supports providers and the care team in maintaining a robust role in high-risk patients’ care plans.

Requirements

Five years of nursing experience.
Experience in case management, home health, medical/surgical nursing, emergency room, or ambulatory care.
At minimum, an LPN credential with successful completion of an approved and accredited Practical Nursing program.
A current Louisiana State Board of Nursing LPN license at minimum.
Basic Life Support (BLS) certification.
Strong leadership, organizational, and interpersonal skills.
Self-direction and good time-management skills.
Excellent written and oral communication and coordination skills.
Excellent problem-solving and critical-thinking skills.
Strong computer skills, including proficient use of an EMR and Microsoft Office suite.
Excellent presentation skills.
Ability to maintain confidentiality of protected health information.
Ability to implement clinically based educational programs.
Ability to use data and evidence-based research to improve patient outcomes and meet quality measures and requirements of Joint Commission, PCMH, and other accrediting bodies.
Ability to manage organizational resources properly.
Ability to support customer satisfaction and engage staff members.

Nice To Haves

Registered Nurse (RN) credential.
Current Louisiana State Board of Nursing RN license.
Certification in a specialty area, if applicable.

Responsibilities

Maintain compliance with federal, state, and local regulations, guidelines, protocols, and standards of care.
Apply Patient Centered Medical Home (PCMH) principles using clinical protocols and tracking tools under clinical leadership.
Work with the care team to provide timely, coordinated, compassionate interdisciplinary care across the organization.
Coordinate care transitions to and from other healthcare facilities or providers.
Assess patients’ physical, mental, and psychosocial needs.
Identify and triage high-risk patients based on disease severity, self-care limitations, support availability, socioeconomic factors, polypharmacy, and healthcare utilization trends.
Maintain a registry of high-risk patients and document completion of measures and interventions.
Initiate care management by educating patients, families, and caregivers about treatment plans and arranging continuous, comprehensive healthcare based on assessed needs.
Use behavioral strategies to help patients adopt healthy behaviors, improve self-care, and manage chronic diseases.
Communicate patient needs and concerns consistently to the multidisciplinary care team.
Under provider direction, respond to patient requests for information about disease processes, treatment plans, medications, and side effects.
Support patients, families, and caregivers during difficult decision-making under provider supervision.
Coordinate care-team planning sessions for patients with poorly controlled conditions, recent hospitalizations, or noncompliance with treatment plans.
Log and track patient referrals to support risk stratification and treatment-plan optimization.
Assist Care Coordinators with patient referrals, consults, support services, results, and reports, and notify providers in a timely manner when follow-up is needed.
Keep current with Electronic Medical Record (EMR) updates to optimize workflows.
Assist Care Coordinators with appropriate EMR documentation and charting.
Develop, maintain, and update care plans to prevent disease exacerbation, improve outcomes, increase patient self-care engagement, reduce risk status, and minimize hospital and ER utilization.
Document and evaluate patient progress and risk status, update care plans, and provide appropriate interventions.
Provide care management and guidance for high-risk patients to reduce hospital admissions, readmissions, and ER visits.
Identify and manage the primary driver of a hospitalization or ER visit.
Maintain tracking and documentation systems for patients admitted to or discharged from hospitals, seen in the ER, or transitioning to or from other healthcare facilities.
Help patients solve problems related to healthcare-system use and financial or psychosocial barriers.
Complete reports and Performance Improvement (PI) activities to demonstrate patient outcomes as needed or directed.
Serve as an educational resource and participate in health fairs and health screenings with the outreach team.
Model professional behavior and Customer Service Excellence.
Support organizational initiatives, including Emergency Preparedness, and demonstrate creativity and flexibility during change.
Participate in committees and attend professional meetings, trainings, and continuing education programs as required.
Perform other assigned or needed duties.