Care Manager Registered Nurse

About the Role

The Care Manager Registered Nurse (CMRN) is a hybrid role responsible for managing a panel of higher-acuity patients (HPP) through a combination of primarily remote case management and targeted in-clinic support, such as High-Risk Huddle meetings. This role is accountable for end-to-end care management, with a strong focus on:

• Reducing avoidable admissions (ADK) and emergency department utilization (EDK)
• Improving clinical outcomes and patient experience
• Supporting care continuity across the healthcare continuum

The CMRN partners closely with providers, clinic staff, and Care Center Managers (CCMs) to deliver coordinated, proactive, and patient-centered care. This position is primarily remote, with regular in-office presence based on patient or program needs.

Responsibilities

Panel Management & Care Coordination (Primarily – Remote)

• Manage a defined panel of high-risk patients, delivering comprehensive, longitudinal case management
• Develop, implement, and continuously update individualized care plans in collaboration with providers and care teams
• Perform ongoing telephonic outreach and monitoring to improve patient outcomes
• Coordinate care across the patients HPC provider, specialists, hospitals, EDs, SNFs, and community resources
• Partner and collaborate with transitions of care team, for a smooth transition and to ensure that the patient needs are met following the transitions of care period

Clinical Collaboration & Outcomes Management

• Partner with providers, MAs, LPNs, and Care Center Managers to align on patient care plans and priorities
• Escalate clinical concerns and barriers to care in real time
• Participate in team huddles, case reviews, and interdisciplinary care discussions
• Track and improve quality and utilization metrics tied to patient outcomes

In-Clinic Responsibilities (Hybrid Component)

• Maintain in-office presence minimum of 1 time a month and as needed to:
  • Support high-risk patient visits
  • Assist with care coordination for complex patients

Home & Community-Based Support

• Coordinate with in office LPN for occasional home visits for high-risk or complex patients when clinically appropriate
• Assess social determinants of health, home safety, and barriers to care
• Coordinate community-based services and resources to support patient care plan goals

Patient & Family Engagement

• Build trusted relationships with patients, families, and caregivers
• Provide education on disease management, medications, and care plans
• Utilize motivational interviewing and coaching techniques to drive behavior change

Program Quality, Compliance & Best Practices

• Adhere to care management protocols, regulatory requirements, and documentation standards
• Support continuous improvement of care management workflows and outcomes
• Identify and report gaps, risks, or adverse events
• Contribute to development of best practices, training, and process improvements

Qualifications

• Active registered nurse (RN) license in North Carolina
• BLS certification
• Experience working in a primary care clinic focused on chronic disease management
• Experience with motivational interviewing, behavior change, health promotion, and coaching
• Strong verbal and written communication skills and customer service orientation

Preferred Qualifications

• Experience with behavioral health and community-based organizations preferred

About You

From a cultural perspective, you are:

• Patient-first, team-oriented
• Agile and thoughtful in a fast-paced environment
• Solutions-driven, always looking to improve
• Accountable, with high standards for yourself and others
• Hands-on and collaborative across diverse teams
• Clear, concise communicator who follows through
• Positive, assuming good intent
• Customer-focused, with a passion for serving patients and providers