Registered Nurse - Care Manager (Full-time, Monday-Friday)
Washington Regional Medical System•Eureka Springs, AR
•Hybrid
About The Position
The Care Manager (CM) supports patients across the care continuum by performing nurse-led Medicare Annual Wellness Visits (AWVs), providing case management and complex care management, and driving enrollment in Advanced Primary Care Management (APCM). This role works closely with providers and clinical operations to close care gaps, improve quality outcomes, and support patients with chronic and complex needs in a value-based care environment. The CM operates within Epic and other care management platforms to document, track, and coordinate patient care activities.
Requirements
- Current, unencumbered RN license in the state of Arkansas
- Minimum 2 years of clinical experience in primary care, case management, or care coordination
- Strong understanding of Medicare AWV, CCM, and/or APCM program requirements
- Proficiency with EHR systems (Epic preferred)
- Excellent communication, organization, and interpersonal skills
Nice To Haves
- Experience in a value-based care or ACO environment
- Familiarity with HEDIS quality measures
- Case Management certification (CCM) or willingness to obtain within a defined timeframe
- Experience with population health/risk stratification tools
Responsibilities
- Independently perform nurse-led AWVs under applicable state scope of practice and CMS direct supervision requirements
- Conduct the full AWV visit, including Health Risk Assessments (HRAs), cognitive screenings, functional/safety screenings, and development of a personalized prevention plan
- Review and reconcile medication lists, screening histories, and immunization status with the patient
- Document the visit to meet CMS requirements for AWV billing (G0438/G0439)
- Identify and close associated quality measure gaps during the visit, per established protocols
- Escalate any clinical concerns to the supervising provider for review and sign-off
- Conduct patient assessments to identify medical, behavioral, and social needs
- Coordinate referrals to community resources.
- Identify patients eligible for Advanced Primary Care Management based on CMS risk stratification criteria
- Educate patients and caregivers on APCM program benefits and obtain consent for enrollment
- Coordinate with billing/compliance staff to ensure documentation supports appropriate service level.
- Manage a caseload of patients with multiple chronic conditions, high utilization, or elevated risk scores
- Develop and maintain individualized care plans in collaboration with the care team
- Perform regular outreach (telephonic, MyChart, in-person) to monitor status and reinforce care plans
- Provide patient and caregiver education on diagnoses, treatment plans, and self-management
- Collaborate with interdisciplinary team members on complex cases
- Escalate urgent clinical concerns per established protocols
- Maintain accurate, timely documentation in Epic consistent with organizational and regulatory standards
- Support HEDIS and other quality measure compliance through accurate coding and gap closure documentation
- Participate in quality improvement initiatives and case reviews
- Track and report on productivity and outcome metrics as defined by leadership
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
