Job Summary

The RN Care Manager is responsible for coordinating care for high-risk and chronic disease patients to improve health outcomes, close gaps in care, reduce avoidable emergency department visits, and hospitalizations. Working collaboratively with providers, care teams, patients, caregivers, and community partners, this position provides patient education, care coordination, chronic disease management support, transition-of-care services, and population health interventions designed to improve patient outcomes and enhance the patient experience.

Required Qualifications

Associate degree in Nursing

Valid Arizona State License as a Registered Nurse

3 years’ clinical nursing experience

Basic Life Support (BLS) certification

Fingerprint Clearance Card through the Arizona Department of Public Safety (may obtain upon hire)

Valid Arizona driver’s license with clean driving record and proof of current vehicle insurance

Preferred Qualifications

Bachelor’s degree in Nursing or related field

Certified Diabetes Care and Education Specialist (SDCES)

Experience in care management, case management, population health, chronic care management, or value-based care

Experience working in a Federally Qualified Health Center (FQHC), community health center, or primary care setting

Experience with electronic health records and population health management tools

Bilingual (English/Spanish)

An equivalent combination of relevant education and experience may be considered in lieu of the requirements above, provided it demonstrates the acquisition of the knowledge, skills, and abilities necessary to successfully perform the job and meets all applicable compliance and regulatory standards.

Knowledge, Skills, and Abilities

Knowledge of evidence-based chronic disease management practices.

Knowledge of care coordination, transition-of-care, and population health principles.

Ability to work independently and collaboratively within a multidisciplinary team.

Ability to assess patient needs and develop appropriate care plans and interventions.

Ability to establish and maintain effective working relationships with patients, families, providers, staff, and community partners.

Ability to prioritize multiple responsibilities in a fast-paced healthcare environment.

Ability to communicate effectively both verbally and in writing.

Commitment to providing compassionate, patient-centered care.

Demonstrated commitment to staff and patient privacy and confidentiality.

Supervisory Responsibilities

May occasionally provide guidance, training, coaching, or technical direction to others.

Essential Duties and Responsibilities

Provides education and support to patients with chronic conditions including, but not limited to, diabetes, hypertension, heart failure, COPD, chronic kidney disease, and other complex medical conditions.

Assists patients in developing self-management skills and achieving individualized health goals.

Monitors patient progress and identifies barriers to treatment adherence and disease management that may impact successful recovery and follow-up care.

Provides medication education and reinforces provider-directed treatment plans.

Coordinates care between primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community resources.

Facilitates communication among members of the care team to ensure continuity of care.

Assists patients with scheduling and completing recommended appointments, screenings, and follow-up services.

Supports referrals and ensures appropriate follow-up documentation and communication.

Conducts outreach and follow-up for patients following emergency department visits, hospitalizations, and other care transitions.

Assists with medication reconciliation and discharge plan review under provider direction.

Promote timely post-discharge follow-up to reduce avoidable readmissions.

Supports organizational quality improvement initiatives and value-based care programs.

Participates in activities designed to improve clinical quality measures, preventive care compliance, and chronic disease outcomes.

Assists in identifying and addressing gaps in care through patient outreach and care coordination activities.

Utilizes population health tools, registries, and reports to prioritize interventions and improve outcomes.

Provides individualized education and coaching to patients and caregivers.

Promotes preventive care, healthy lifestyle choices, and disease self-management.

Connects patients with community resources that address social determinants of health and support overall well-being.

Encourages patients’ engagement in their healthcare and treatment plans.

Documents patient encounters accurately and timely within the electronic health record.

Maintains compliance with organizational policies, HIPAA regulations, and applicable state and federal requirements.

Participates in required meetings, trainings, and quality improvement activities.

Performs other duties as assigned.

Physical Demands

Moderately active work with extended periods of computer use and frequent direct patient interaction[KL1]