Community Registered Nurse (RN) Care Manager

About The Role

The Registered Nurse (RN) Care Manager is a community-based, field role that partners closely with our Nurse Practitioners and interdisciplinary care team to deliver coordinated, relationship-focused care to older adults living in affordable housing communities.

• Conduct comprehensive nursing assessments in patients' homes and community settings
• Partner with Nurse Practitioners and Medical Directors to support high-risk and rising-risk patients
• Coordinate care with specialists, primary care providers, hospitals, health plans, and community organizations
• Educate patients on chronic disease management, medication adherence, preventive care, and healthy lifestyle choices
• Support patients through transitions of care following hospitalizations or emergency department visits
• Identify and close quality care gaps through patient outreach, education, and care coordination
• Reinforce care plans developed by providers while documenting barriers and follow-up needs
• Build trusted, long-term relationships with patients and their families
• Document patient interactions and care activities using Athena, Salesforce, and other technology platforms

What We're Looking For

• Active, unrestricted Registered Nurse (RN) license
• Minimum of 3 years of RN experience
• Experience working independently in community, home-based, or field settings preferred
• Experience in care management, case management, primary care, value-based care, home health, or chronic disease management preferred
• Strong communication, organization, and relationship-building skills
• Passion for serving older adults and improving healthcare access
• Comfortable working independently while collaborating with an interdisciplinary care team
• Experience with electronic health records (EHRs) and healthcare technology
• Valid driver's license and reliable transportation