RN Case Manager

Kinston Community Health•Kinston, NC

33d

About The Position

The RN Case Manager provides comprehensive care management and coordination services for high-risk and complex patient populations at Kinston Community Health Center. This role conducts clinical and psychosocial assessments, develops and implements individualized care plans, manages high-risk patient registries, and supports Chronic Care Management (CCM) and Patient-Centered Medical Home (PCMH) initiatives. The RN Case Manager collaborates closely with interdisciplinary care teams, community partners, and payer-based programs to facilitate care transitions, improve patient outcomes, and reduce avoidable emergency department and hospital utilization, while ensuring accurate documentation, regulatory compliance, and alignment with KCHC’s mission and values.

Requirements

Associate Degree in Nursing (ADN) required
Current, unrestricted Registered Nurse (RN) license in the State of North Carolina
Current BLS certification with the ability to effectively perform CPR in emergency situations, or ability to obtain within 3 months of employment
Minimum of two (2) years of clinical nursing experience as a Registered Nurse
Experience in care coordination, care planning, case management, and clinical documentation
Experience managing chronic conditions and supporting high-risk or complex patient populations
Demonstrated ability to collaborate with interdisciplinary care teams and community partners
Strong organizational and time-management skills
Proficiency with electronic health records (EHRs) and health management systems
Working knowledge of Microsoft Office Suite
Clinical assessment and individualized care planning
Care coordination and patient advocacy
Effective communication and patient education skills
Accurate, timely clinical documentation
Ability to work independently and collaboratively within an interdisciplinary team

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred

Responsibilities

Conduct comprehensive assessments of patients’ physical, mental, and psychosocial needs.
Develop and implement individualized care plans to improve outcomes, increase patient engagement in self-care, reduce risk status, and minimize emergency department and hospital utilization.
Utilize behavioral strategies and motivational techniques to support chronic disease self-management and healthy behavior change.
Provide ongoing follow-up and monitoring, including telephone follow-ups within 24 hours of inpatient discharge and 48 hours of ED or hospital visit notification.
Manage KCHC’s high-risk patient registry, including identification through the EHR, provider referrals, and payer-supplied registries.
Ensure accuracy and validity of patient registries and documentation.
Utilize Chronic Care Management (CCM) templates in NextGen, primarily for the Medicare population.
Maintain up-to-date knowledge of community resources to support disease management and connect patients as appropriate.
Develop and maintain systems to track care coordination and care management activities across the continuum of care, including primary care, specialty care, and care transitions.
Serve as a clinical liaison for payer-based care management programs.
Collaborate with external case management programs, community partners, and internal care teams to coordinate patient care.
Participate actively as a member of interdisciplinary, team-based care initiatives.
Proactively support Patient-Centered Medical Home (PCMH) initiatives related to care coordination.
Partner with PCMH staff to develop and enhance integrated care management programs.
Participate fully in the organization’s performance improvement and corporate compliance programs.
Ensure adherence to HIPAA and OSHA standards in all clinical activities.
Maintain accurate, timely, and complete clinical documentation in the electronic health record.
Monitor patient progress and risk status and communicate effectively with care teams and providers.
Participate in continuing professional development, including workshops, in-services, and independent learning.
Attend and participate in organizational meetings, functions, and administrative activities as required.
Participate as a member of the emergency response team for patient emergencies.
Perform other duties as assigned to support organizational and patient care needs.