Job Overview
The Nurse Care Manager serves as the clinical anchor for medically and socially complex geriatric patients, offering an opportunity to transition away from bedside burnout into a rewarding, relationship-based outpatient model. This position involves a hybrid rotation.
- Work-Life Balance: Monday–Friday, 8:00 AM – 4:30 PM (No weekends, holidays, or on-call requirements).
- Dynamic Setting: Hybrid clinic rotation providing variety and collaborative practice.
- Long-Term Impact: Focuses on building lasting provider-patient partnerships and improving patient quality of life.
The Nurse Care Manager guides geriatric patients through care transitions across hospitals, rehab, and home while managing chronic conditions like dementia and CHF. Grounded in Age-Friendly Health System principles, the Nurse Care Manager conducts comprehensive assessments to craft individualized care plans, triages clinical communications, and provides vital education to patients and caregivers. Working closely with an interdisciplinary team of providers, social workers, and pharmacists, the care manager addresses social determinants of health and connects families with community resources to remove barriers to care and improve quality of life.
Responsibilities
Care Coordination & Clinical Support
- Serve as the primary point of contact for medically and socially complex patients and their caregivers.
- Coordinate care across primary care, specialty clinics, home health, rehabilitation facilities, and community partners.
- Facilitate transitions of care (hospital → home, rehab → outpatient, assisted living, long-term care, hospice).
- Monitor chronic disease management (e.g., dementia, frailty, CHF, COPD, diabetes) and identify early signs of decompensation.
- Review and triage incoming clinical messages and calls related to care coordination, patient needs or concerns requiring follow-up.
- Conduct routine check-ins in all clinic locations to support providers, staff, and patients, ensuring timely response to questions and identification of emerging patient needs.
Patient Assessment & Care Planning
- Conduct comprehensive geriatric assessments addressing medical, functional, cognitive, psychosocial, and environmental needs.
- Develop individualized care plans in collaboration with providers and the interdisciplinary team, incorporating Age-Friendly Health System principles (What Matters, Medication, Mentation, Mobility).
- Identify gaps in care, medication concerns, fall risks, cognitive decline, and safety risks; escalate appropriately.
- Support patients and caregivers managing chronic conditions by reinforcing care plans, educating on self-management, and helping navigate complex care systems.
Social Support & Resource Navigation
- Assess and address social determinants of health impacting older adult outcomes (transportation, caregiving strain, financial barriers, food insecurity, isolation).
- Connect patients and caregivers with community resources, caregiver supports, and state/local services.
- Assist with long-term care planning, home health needs, durable medical equipment, and referrals to senior services or palliative care.
- Advocate for patients and families to ensure access to appropriate services and supports.
Communication & Collaboration
- Maintain close communication with providers about patient needs, care barriers, and changes in condition.
- Collaborate with social work, nursing, pharmacy, therapy services, and community agencies.
- Participate in interdisciplinary team meetings, including GAC IDT meetings and case reviews, to discuss complex patients and adjust care strategies.
- Provide guidance and support to caregivers navigating dementia, functional decline, or other patient specific challenges.
Advocacy & Patient Support
- Serve as an advocate for patients and families navigating complex medical and social systems.
- Support caregivers managing stress, burnout, and complex care responsibilities.
- Assist with insurance or coverage questions within the scope of nursing practice.
Documentation & Compliance
- Document all care coordination activities, assessments, care plans, follow-up calls, and resource referrals in the EMR.
- Track patient progress, outstanding care needs, and follow-up items.
- Ensure communication and follow-up comply with clinic protocols, state requirements, and organizational policies.
- Identify safety concerns (e.g., potential elder abuse or neglect) and escalate per mandatory reporting guidelines.
Education & Problem-Solving
- Provide patient and caregiver education on medications, disease processes, self-management strategies, and available resources.
- Independently research resources, troubleshoot barriers to care, and develop patient-centered solutions.
- Support staff education on geriatric-specific issues, social determinants of health, and interdisciplinary care coordination.
Required Qualifications
Education:
Bachelor's degree
Certifications/Professional Licenses:
The list below may include all acceptable certifications, professional licenses and issuers. More than one credential, certification or professional license may be required depending on the role.
Basic Life Support - American Heart Association, Basic Life Support - American Red Cross, Registered Nurse - Illinois Department of Financial and Professional Regulation, Registered Nurse - Missouri Division of Professional Registration
More About This Job
Required Qualifications:
- Registered Nurse in the state of Missouri or Illinois.
- Basic Life Support certification (Online BLS certifications, those without a skills assessment component, are not sufficient to meet the BLS requirements).
Preferred Qualifications
Work Experience:
RN with at least one year of nurse care management experience.
Benefits
Personal
- Up to 22 days of vacation, 10 recognized holidays, and sick time.
- Competitive health insurance packages with priority appointments and lower copays/coinsurance.
- Take advantage of our free Metro transit U-Pass for eligible employees.
- WashU provides eligible employees with a defined contribution (403(b)) Retirement Savings Plan, which combines employee contributions and university contributions starting at 7%.
Wellness
- Wellness challenges, annual health screenings, mental health resources, mindfulness programs and courses, employee assistance program (EAP), financial resources, access to dietitians, and more!
Family
- We offer 4 weeks of caregiver leave to bond with your new child. Family care resources are also available for your continued childcare needs. Need adult care? We’ve got you covered.
- WashU covers the cost of tuition for you and your family, including dependent undergraduate-level college tuition up to 100% at WashU and 40% elsewhere after seven years with us.
For policies, detailed benefits, and eligibility, please visit: https://hr.wustl.edu/benefits
EEO Statement
Washington University in St. Louis is committed to the principles and practices of equal employment opportunity. It is the University’s policy to provide equal opportunity and access to persons in all job titles without regard to race, ethnicity, color, national origin, citizenship (where prohibited by federal law), age, religion, sex, sexual orientation, gender identity or expression, disability, protected veteran status, or genetic information.
Pay: $64,500.00 - $109,900.00 per year
Benefits:
- 403(b)
- 403(b) matching
- Continuing education credits
- Dental insurance
- Employee assistance program
- Employee discount
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid sick time
- Paid time off
- Parental leave
- Retirement plan
- Tuition reimbursement
- Vision insurance
- Wellness program
People with a criminal record are encouraged to apply
Application Question(s):
- What is you salary expectation given the role?
Experience:
- Nurse Care Management: 1 year (Required)
Work Location: Hybrid remote in Saint Louis, MO 63109
