Population Health RN Case Manager – Family Medicine, Centerfield

Job Summary

The RN Case Manager works collaboratively with physicians, interdisciplinary teams, patients, and families to promote positive patient outcomes through transitions of care and longitudinal care management. The RN Case Manager performs comprehensive assessments, develops individualized care plans, coordinates services across the continuum of care, and supports patients in achieving their health goals. The RN Case Manager serves as the primary clinical resource for high-risk patients and those recently discharged from acute care settings. In addition to nursing case management responsibilities, the role provides psychosocial support and assists patients with social determinants of health needs, including transportation, housing, food insecurity, financial assistance, and community resource referrals. Complex behavioral health and social work needs are escalated or referred appropriately.

Key Responsibilities

• RN Case Management (Approximately 80–90%)
  • Provide transitional care management following emergency department visits and hospital discharges.
  • Manage longitudinal care for high-risk and medically complex patients.
  • Perform comprehensive assessments and develop individualized care plans.
  • Monitor patient progress and modify care plans as needed.
  • Carefully coordinate care across primary care, specialty care, hospitals, home health agencies, and community organizations.
  • Promote disease self-management, medication adherence, preventive care, and patient education.
  • Collaborate with providers and interdisciplinary teams to improve quality and value-based care outcomes.
  • Serve as a patient advocate and clinical liaison with outside agencies and healthcare partners.
  • Maintain accurate documentation and participate in quality improvement initiatives.
• Social Determinants of Health and Resource Navigation (Approximately 10–20%)
  • Assess psychosocial barriers affecting health outcomes.
  • Aid patients with access to transportation, housing, food resources, financial assistance, insurance programs, and other community resources.
  • Provide emotional support and crisis intervention within scope of practice.
  • Facilitate referrals to behavioral health, social work, and community-based organizations as appropriate.
  • Educate patients and families regarding available support services.
  • Collaborate with social workers, behavioral health providers, and community partners to address non-medical needs affecting health.

Work Location

Hybrid – this role is eligible for a hybrid schedule of 4 days per week in clinic located in Denver, CO and as needed for in-person meetings.

Qualifications

• Minimum Qualifications: Bachelor’s degree in nursing, biological science, or a directly related field from an accredited institution.
• Two (2) years of registered nurse experience in a clinical/hospital setting.
• One (1) year of experience in case management in specialty area.
• A combination of education and related technical/military/paraprofessional experience may be substituted for a bachelor’s degree on a year for year basis.
• Preferred Qualifications: Three or more (3+) years registered nurse experience in a clinical/hospital setting.
• Two or more (2+) years of experience in case management in specialty area.
• Experience with transitions of care and ambulatory longitudinal care management.
• Experience addressing social determinants of health and community resource coordination.
• Experience in primary care, population health, or value-based care.
• Bilingual, Spanish-speaking.
• Nursing certification (ANCC) in specialty area.
• Kronos, Epic, and Health Stream experience.