LPN/RN Nurse Care Manager

Key Responsibilities

• Manage a caseload of up to 250 Health Care Home patients
• Complete annual care plans and ongoing monitoring of patients’ medical needs
• Develop and support health-related treatment plan goals for patients with chronic conditions
• Provide client education on health conditions, medications, prevention, and self-care
• Collaborate with primary care providers, care teams, and specialists to coordinate comprehensive care
• Monitor patient records, reports, and alerts (e.g., hospital admissions, medication needs) using HIT tools and EMRs
• Perform medication reconciliations after hospital discharges and assist with follow-up care
• Analyze data and trends (e.g., DRVS reports) and contribute to performance improvement efforts
• Support documentation and tracking of Uniform Data System (UDS) quality measures
• Serve as a clinical resource for patients, staff, and care team members
• Participate in multi-disciplinary team meetings and contribute to holistic care planning
• Seek and provide culturally responsive services to meet individual and family needs
• Report to the Regional Primary Care Nursing Director for clinical supervision and support

Requirements, Skills, Knowledge and Expertise

• Bachelor’s degree in nursing preferred

• Proficiency in Microsoft Office Suite and Electronic Medical Records preferred

• Licensed Practical Nurse (LPN) or Registered Nurse (RN) required

• Are passionate about person-centered care and chronic disease management
• Feel confident navigating both primary care and behavioral health systems
• Excel in team-based settings and value collaboration with other providers
• Stay organized and detail-oriented in fast-paced clinical environments
• Are proactive in using data and health IT tools to drive patient outcomes
• Believe that integrated care is essential for promoting long-term wellness