RN Care Manager in Outpatient Family Medicine

Unity Care NW•Bellingham and Ferndale, WA

17h•Hybrid

About The Position

The RN Care Manager is responsible for providing proactive, population-based, patient-centered care management to a defined panel of patients within a team-based primary care model. This role focuses on chronic disease management, preventive care gap closure, transitions of care, and patient self-management support. Unity Care NW is a private, non-profit, federally qualified health center (FQHC) serving the greater Whatcom County area since 1982, offering comprehensive primary medical, behavioral health and dental care, as well as pharmacy services to a diverse and often underserved patient population of all ages. Our mission is to increase the years of healthy life in the people & communities we serve.

Requirements

Formal BSN degree program
Washington State RN License
Ambulatory Care Nursing Board Certification (AMB-BC™) - if not currently certified, must obtain within first year of employment and we'll reimburse the certification exam fee after passing the exam
At least one year demonstrated experience in care management, care coordination, or population-based nursing (e.g. chronic disease management, transitions of care, preventive outreach)
Strong clinical assessment, care planning, and patient education skills
Basic Life Support (BLS) Certification (can get certified when starting)
Ability to use the following software: Microsoft Outlook, Microsoft Word, Electronic Medical Records (we use Epic), patient scheduling system, HR/Payroll program for timesheets, training systems and SharePoint.
Ability to understand and respond effectively and with sensitivity to special population groups, including those defined by race, ethnicity, language, age, gender, sexual orientation, economic standing, and others.
Ability to work at both our Bellingham and Ferndale locations on a regular basis

Nice To Haves

At least two years’ experience with outpatient clinic responsibilities
Ability to communicate bilingually in English & Spanish a plus.

Responsibilities

Performs direct patient care and RN-driven care management for empaneled patients from prioritized patient populations.
Collaborates with Medical Leadership in identifying priority populations and defining entry and exclusion criteria.
Conducts proactive and regular outreach using registries, reports, and risk stratification tools.
Coordinates care across the care team, including providers, MAs, behavioral health, pharmacy, case management, referrals, and external partners.
Keeps patients’ primary care provider informed on progress, needs and potential barriers.
Serves as consistent point of contact for patients enrolled in care management.
Enrolls eligible patients in and discharges patients from care management based on established criteria.
Monitors disease-specific outcomes (e.g. blood pressure, HbA1c) and intervenes using approved protocols and standing orders.
Identifies and closes preventive care gaps (e.g. screenings, labs, immunizations).
Provides patient education, coaching, and goal setting using motivational interviewing techniques.
Completes hospital and emergency department follow-up outreach within established timelines.
Performs medication reconciliation and symptom assessment post-discharge.
Coordinates follow up appointments, labs, and referrals to reduce readmissions and care fragmentation.
Develops and maintains individual, person-centered care plans in collaboration with patients and providers.
Screens for social drivers of health, depression, anxiety, and barriers to care.
Ensures all care plans include targeted completion dates and timelines for monitoring and follow-up.
Meets with patients in accordance with their care plan and documents all care management activities accurately and timely in electronic health record.
Uses standardized documentation tools, templates, and workflows consistent with Patient Centered Medical Home requirements.
Participates in quality improvement initiatives and supports achievement of quality goals related to care management.
Plays a lead role in the development and refinement of RN care management protocols and workflows.
Tracks and reports care management metrics as assigned.
Collaborates with leadership to evaluate program effectiveness and opportunities for expansion.

Benefits

Medical, dental, & vision insurance
401(k) retirement plan with employer match after 1 year of eligibility
6 paid holidays
Generous paid time off of 108 hours accrued in Year 1, 156 hours accrued in Year 2 and gradually increasing to 196 hours accrued per year over 10 years
Paid sick leave accrued at 1 hour per 40 hours paid
Other paid leaves for Bereavement, Jury Duty & Bone Marrow/Organ Donation
Life/Accidental Death & Dismemberment (AD&D) insurance
Variety of optional insurances including Supplementary Life/AD&D, Short Term and Long Term Disability, Critical Illness, Accident, and Travel as well as Identity Theft Protection
Flexible Spending Account
Self-funded Health Savings Account on Base Medical Insurance Plan
Employee Assistance Program
Alternative transportation incentives
Healthy Living reimbursement
Unique programs including Medical Hardship Payroll Loans, Employee Referral Bonuses & Will preparation services
Continuing Education (days & funds)
Reimbursement of Washington State license renewal fees
Loan Repayment Application Opportunities
Eligible providers may apply for loan repayment through the Washington Student Achievement Council (Washington Health Corps | WSAC)
Eligible providers may apply for loan repayment through the Nurse Corps Loan Repayment Program