Nurse Care Manager - General Medicine & Geriatrics

Washington University in St. Louis

6d•Hybrid

About The Position

The Nurse Care Manager provides expert care coordination within a dynamic, multi-site outpatient environment, moving away from bedside burnout into a relationship-based model that prioritizes long-term patient impact. The Nurse Care Manager acts as a clinical anchor by coordinating high-risk interventions, bridging care transitions, and fostering provider-patient partnerships to resolve health hurdles and improve patient quality of life.

Requirements

Bachelor's degree
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).
Registered Nurse - Illinois Department of Financial and Professional Regulation
Registered Nurse - Missouri Division of Professional Registration
Basic Life Support - American Heart Association
Basic Life Support - American Red Cross

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

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.
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.
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.
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.
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.
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.
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
Sick time
Competitive health insurance packages with priority appointments and lower copays/coinsurance.
Free Metro transit U-Pass for eligible employees.
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
4 weeks of caregiver leave to bond with your new child.
Family care resources are also available for your continued childcare needs.
Adult care resources.
Tuition coverage for you and your family, including dependent undergraduate-level college tuition up to 100% at WashU and 40% elsewhere after seven years with us.