RN Care Manager

CareAbout

About The Position

The Care Manager, RN (CM-RN) will serve as an integral member of a multidisciplinary healthcare team in a primary care setting. This role focuses on patient coaching, care coordination, and navigation for individuals with complex medical needs. The CM-RN will support the practice in developing and implementing processes for managing high-risk populations, promoting patient-centered care, and partnering with providers to achieve optimal outcomes. The CM-RN will play a key role in advancing the practice’s value-based care and alternative payment model (VBC/APM) initiatives.

Requirements

Florida RN degree required; current Florida RN license mandatory.
Minimum 5 years of direct patient care experience.
Knowledge of utilization management, case/care management principles, healthcare contracts, and hospital payment systems.
Strong independent judgment and confidentiality.
Analytical and problem-solving skills with attention to detail and data.
Excellent communication, interpersonal, and organizational skills.
Ability to manage multiple priorities, follow up effectively, and meet deadlines.
Proactive, dependable, and demonstrates high integrity.
Competence in MS Word, Outlook, PowerPoint, and Excel.
Primarily sedentary; sitting at a desk most of the day.
Standing or walking less than two hours per day.
Occasional lifting up to 10 pounds.
Frequent use of computer and phone.

Nice To Haves

Care management experience preferred; Certified Case Manager (CCM) certification a plus.
Experience with APMs (CPC+, BPCI, MSSP) and Medicare Advantage preferred.
Experience across acute inpatient, rehabilitation, sub-acute, skilled nursing, home care, ambulatory care, or managed health plans desirable.

Responsibilities

Build and maintain constructive relationships with hospital admission offices, case managers, and discharge planners.
Develop systems, processes, and initiatives to engage hospitals and post-acute care providers in relevant case management activities.
Ensure coordinated care with home care agencies, specialists, and other necessary resources.
Monitor and facilitate follow-up primary care visits within 24 hours of hospital discharge.
Conduct comprehensive patient assessments, including medical, psychosocial, and functional evaluations, aligned with patient-centered medical home standards.
Communicate and coach patients on discharge instructions, medications, and self-management strategies.
Ensure appropriate home care, hospice, and ancillary services (e.g., DME, infusion) are in place and delivered effectively.
Coordinate referrals, authorizations, and information flow between providers, hospitals, and care teams.
Identify high-risk, high-need, and potentially high-cost patients in collaboration with physicians.
Support implementation of preventive, chronic care, and disease management best practices.
Facilitate behavioral health screenings and follow-up care as needed.
Attend required training, collaboration sessions, and care management meetings.
Obtain necessary medical records for care coordination efforts.
Other duties as assigned.