The RN Care Manager is a key member of the primary care team, focusing on the coordination of care for patients with complex medical needs, chronic conditions, and high-risk social determinants of health. Unlike a traditional floor nurse, this role is centered on population health management, patient education, and bridging the gap between clinical visits to prevent hospitalizations and improve long-term outcomes.
Key Responsibilities
- Care Coordination & Planning:
- Develop and implement individualized care plans for high-risk patients (e.g., Diabetes, COPD, CHF, Hypertension).
- Identify patient barriers to care (transportation, financial, literacy) and provide resources or referrals.
- Facilitate transitions of care by following up with patients within 48 hours of hospital discharge or ER visits.
- Conduct telephonic or in-person nursing assessments to monitor patient progress.
- Perform medication reconciliation and education to ensure adherence.
- Order and track laboratory tests or screenings as per standing orders and protocols.
- Coach patients on self-management skills and lifestyle modifications.
- Utilize motivational interviewing techniques to encourage behavioral changes.
- Act as a liaison between the patient, the Primary Care Provider (PCP), specialists, and community agencies.
Qualifications & Skills
- Associate’s or Bachelor’s Degree in Nursing (BSN preferred).
- Licensure - Active, unrestricted Registered Nurse (RN) license in the state of NC.
- 3+ years of clinical nursing experience; experience in home health, case management, or primary care is a plus.
- Autonomous problem-solving, and excellent telephonic communication.
Full- time, Monday through Friday 8:00 a.m. - 5:00 p.m..
Job Type: Full-time
Pay: $60,000.00 - $70,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
Application Question(s):
- If you do not currently live in the New Bern, NC or surrounding area, what is your time frame for relocation?
Work Location: In person
