Nurse Care Manager

What You'll Do

• Identify and prioritize high-risk, high-utilizing patients using population health tools and data to target interventions that reduce preventable hospitalizations and emergency visits.
• Develop and manage individualized care plans with clear goals, evidence-based interventions, and structured follow-up tailored to each patient’s needs.
• Manage patient panels by closing preventive and chronic care gaps while improving performance on quality and value-based care measures.

• Lead transitional care management, ensuring smooth hospital-to-home transitions through timely outreach, medication reconciliation, and follow-up care.
• Partner with primary care, behavioral health, and interdisciplinary teams to deliver coordinated, integrated care.
• Facilitate case conferences and treatment planning to support shared patients and optimize outcomes.

• Proactively engage patients through outreach and coaching strategies that improve adherence, self-management, and health literacy.
• Address social determinants of health by connecting patients to internal and community-based resources that remove barriers to care.
• Use motivational interviewing and culturally responsive communication to build trust and drive meaningful behavior change.

• Conduct ongoing assessments and adjust care plans based on patient condition, risk, and utilization patterns.
• Monitor hospital utilization trends and implement targeted interventions to reduce avoidable admissions.
• Ensure accurate, compliant documentation that supports quality reporting, regulatory requirements, and value-based care initiatives such as MSSP and payer contracts.

• Serve as a key liaison across providers, community partners, and programs to ensure seamless, integrated service delivery.
• Participate in interdisciplinary meetings and organizational initiatives to improve population health and patient experience.
• Provide clinical support, including direct RN functions as needed, to ensure continuity and excellence in care delivery.

Required Credentials & Experience

Benefits

• Subsidized, comprehensive medical (BCBSRI) and dental (Delta Dental) insurance plans 
• Supplemental vision insurance (Delta Dental)
• Voluntary medical and dependent care flexible spending accounts
• Up to 3% matching 403(b) retirement plan
• Employer-paid life insurance 
• Generous paid time off including vacation, holidays, personal days, and sick time
• Mileage reimbursement
• Tuition reimbursement
• Employer-paid professional development 
• Employee assistance program