RN CARE MANAGER

ANCHORAGE NEIGHBORHOOD HEALTH CENTER INC•Anchorage, AK

21d•Onsite

About The Position

The RN Care Manager provides intensive, relationship-based care coordination for medically and socially complex patients at high risk for emergency department utilization, hospitalization, poor health outcomes, and fragmented care. The role helps patients navigate the healthcare system, improve engagement in primary care, reduce avoidable utilization, and address barriers affecting health and wellness. The RN Care Manager serves as a central coordination point for an active panel of high-need patients, emphasizing proactive outreach, transitional care management, chronic disease support, depression and mental health screening, patient advocacy, and coordination across care settings. The position identifies and enrolls patients using clinical, utilization, and social complexity criteria; maintains and periodically reassesses an active panel; and develops individualized care plans with patients and care teams. It coordinates care across primary care, behavioral health, specialty care, hospitals, emergency departments, pharmacies, and community organizations, including structured follow-up after emergency department visits and hospitalizations. Patient engagement may take place by phone, text, telehealth, and in person. Clinical support includes medication reconciliation after discharge or care transitions, administration and tracking of standardized screening tools, and monitoring adherence to evidence-based care plans. The RN Care Manager documents work in the electronic health record, participates in team meetings and quality improvement, and tracks program outcomes. The position provides coverage for other RN Care Managers as needed and may assist with onboarding and training clinical staff. Work is performed in a healthcare clinic and office setting. The work is frequently sedentary, with occasional walking and standing, and may occasionally involve lifting or moving up to 20 pounds. ANHC is a tobacco-free campus.

Requirements

Four years of progressively responsible nursing experience in primary care, ambulatory care, community health, or a population health setting.
Active Registered Nurse license in the State of Alaska.
Current BLS certification, which must be maintained.
Maintain current knowledge of evidence-based practices, clinical guidelines, population health strategies, and care management principles relevant to the patient populations served.
Participate in ongoing professional development, continuing education, training, and competency development.
Demonstrate accountability, adaptability, confidentiality, effective communication, sound judgment, quality work, initiative, results orientation, service excellence, and teamwork.

Nice To Haves

Experience working within a Patient-Centered Medical Home (PCMH) model.
Bilingual skills.

Responsibilities

Identify patients who may benefit from high-utilizer care management using clinical, utilization, and social complexity criteria, with emphasis on sustained or escalating utilization patterns.
Use population health tools, registries, risk stratification reports, screening results, and utilization data to identify and prioritize patients at risk for or living with chronic health conditions.
Participate in interdisciplinary case review and patient prioritization, incorporating data-driven identification and provider or team referrals.
Maintain an active panel of high-risk patients appropriate to program capacity and reassess enrollment using defined step-down and graduation criteria.
Develop individualized, patient-centered care plans in collaboration with patients and care teams, incorporating patient-defined goals and preferences.
Coordinate care across primary care, behavioral health, specialty care, hospitals, emergency departments, pharmacies, and community organizations.
Provide structured transitional care management after emergency department visits and hospitalizations.
Help patients address barriers involving transportation, housing instability, medication access, insurance, food insecurity, and healthcare system navigation.
Facilitate warm handoffs between team members and services, and coordinate with community providers to extend outreach, social support, coaching, advocacy, and navigation.
Build therapeutic, trauma-informed relationships with patients experiencing complex medical, behavioral health, and social challenges.
Conduct patient outreach by phone, text, telehealth, and in-person encounters.
Educate patients about chronic disease management, medications, preventive care, and treatment plans.
Use motivational interviewing to promote engagement in chronic condition prevention and management, behavioral health, lifestyle modification, disease self-management, and community-based support programs.
Perform medication reconciliation following hospital discharge or transitions of care.
Administer and track standardized screening tools.
Monitor adherence to evidence-based care plans for chronic disease prevention and management, escalating concerns and care gaps to appropriate clinical team members.
Assist with preventive care coordination and follow-up appointments, and support safe care transitions and continuity of care.
Provide coverage for other RN Care Managers as needed.
Participate in interdisciplinary team meetings, case conferences, monthly clinic meetings, Nursing Department meetings, and daily POD huddles.
Accurately document patient interactions, care plans, screening results, and outcome measures in the electronic health record.
Use registries, reports, and utilization data to guide patient management and track program outcomes.
Collaborate with leadership on quality improvement initiatives and contribute to program evaluation by tracking and reporting key performance indicators.
Assist with onboarding and training of clinical staff as indicated.
Support ANHC's mission, vision, and values; maintain confidentiality and comply with HIPAA.