Nurse Care Manager

About the role

Under the supervision of the Nursing Manager, the Nurse Care Manager-CCM (NCM) evaluates and provides case management services for patients with complex medical and social needs. The NCM works on a multidisciplinary healthcare team in a primary care setting, collaborating with primary care providers, pharmacists, community health workers, and behavioral health specialists. This role focuses on comprehensive screenings, care coordination, disease education, and culturally sensitive, patient-centered self-management support for patients with chronic health conditions.

Responsibilities

• Retrieve monthly high-risk lists and proactively outreach to enroll patients in complex case management.
• Collaborate with Primary Care Physicians (PCPs) to prioritize patients identified for complex case management.
• Coordinate with PCP offices to meet patients face-to-face before, during, or after scheduled visits, including conducting home visits as necessary.
• Conduct comprehensive assessments to evaluate patients’ physical, functional, social, psychological, environmental, learning, and financial needs.
• Identify and prioritize problems, goals, and interventions that align with patient/caregiver goals, preferences, and desired involvement in the case management plan.
• Create patient-centered care plans, including self-management goals and culturally sensitive interventions.
• Provide education, information, and support related to care goals, disease prevention, and health promotion.
• Implement and monitor care plans, adjusting as needed to ensure effectiveness.
• Communicate regularly to evaluate patient progress, identify barriers, and reassess goals or health status.
• Support transitions between healthcare facilities to ensure continuity of care and avoid unnecessary readmissions.
• Evaluate and customize case management plans to help patients achieve goals.
• Coordinate care with PCPs, specialists, interdisciplinary teams, and other providers.
• Monitor tests, labs, and medications against standard-of-care guidelines and communicate discrepancies with the PCP.
• Provide referrals to community resources and facilitate access to services while avoiding duplication.
• Act as a patient advocate to address barriers to care or compliance with the care plan.
• Maintain accurate patient records and confidentiality.
• Engage in professional development to stay current with case management practices and patient engagement strategies.

Medical Management

• Participate in prospective, concurrent, and retrospective case reviews/care conferences with the interdisciplinary team, Chief Medical Officer, and payers.
• Apply and document relevant information following department policy guidelines.
• Maintain knowledge of operational policies, procedures, and case management program components.
• Promote chronic disease management, health screenings, and preventive health initiatives.
• Stay updated with the latest research and best practices in disease management to deliver evidence-based care.

Program Management

• Participate in and promote performance improvement projects.
• Develop, implement, and evaluate department initiatives and goals as assigned.
• Troubleshoot problems related to operational and clinical procedures.
• Participate in quality performance initiatives and data collection/analysis.
• Contribute to the development and implementation of condition-specific, evidence-based protocols.

General Requirements

• Maintain accurate and up-to-date medical records and documentation.
• Perform quality work within deadlines, with or without direct supervision.
• Share best practices, serve as a medical home advocate, and mentor team members to foster a positive work environment.
• Represent the practice, department, and organization positively to patients and external clients.
• Escalate issues to appropriate managers in a timely manner.
• Participate in initiatives supporting the Rhode Island healthcare community.
• Perform other related duties as assigned.

Qualifications

• Licensed RN in the State of Rhode Island.
• 3–5 years of experience in community health, public health, chronic disease management, or community nursing; case management preferred.
• Minimum of 2 years’ experience managing patients with complex medical and social needs.
• Certified as a diabetic educator or in another chronic care area, or willing to obtain certification within 12 months of employment.

Skills

• Flexibility and adaptability in implementing change.
• Knowledge and skill in chronic disease management.
• Ability to initiate end-of-life conversations with patients, providers, and caregivers when appropriate.
• Ability to work independently and collaboratively to achieve goals.
• Highly organized with strong attention to detail.
• Ability to develop and manage relationships with interdisciplinary teams, patients, caregivers, and providers.
• Strong interpersonal, relationship-building, and communication skills (written and verbal).
• Proficiency in exercising sound judgment, critical thinking, and decision-making.
• Ability to multitask, assess, and manage competing priorities.
• Proficiency with computer skills (e.g., Microsoft Word, Excel, Access, and web-based applications).
• EMR experience preferred.
• Ability to maintain confidentiality in accordance with HIPAA.
• Bilingual (Spanish) is a strong asset but not required.
• Demonstrates compassion and empathy.
• Active and unrestricted driver’s license.

Physical Requirements

• Prolonged periods of sitting at a desk and using a computer.
• Able to sit, stand, and walk for long periods, including entering and exiting offices and healthcare buildings.
• Workspace environments may vary, including offices with stairs and no elevators or ramps.
• Must be able to travel between home, RIPCPC premises, and provider offices.
• Must be able to lift up to 15 pounds at times.

About Us

Rhode Island Primary Care Physicians Corporation (RIPCPC) is a multi-specialty Independent Practice Association (IPA) implementing innovative quality improvement models since 1994. As a population health management organization, RIPCPC focuses on improving outcomes for physician members’ patients. We are committed to the National Committee for Quality Assurance’s Patient-Centered Medical Home (PCMH) model and have implemented more PCMHs than any other organization in Rhode Island. RIPCPC joined Akido Labs in 2023, becoming a key east coast hub for healthcare innovation within the Akido Care medical network.

Pay

Salary range: $80,000 USD – $90,000 USD.