RN CARE MANAGER - Chronic Disease Management

RN CARE MANAGER - Chronic Disease Management

Duties and Responsibilities:?

Population Health Management

Utilize data analytics and risk stratification tools to identify target populations.

Monitor patient progress and outcomes using electronic health records (EHR) and population health platforms.

Develops and implements targeted intervention strategies.

Participate in quality improvement initiatives and performance metrics tracking. Care Coordination

Identify and engage patients with chronic diseases, high-risk conditions, or social determinants of health impacting care.

Develop individualized care plans in collaboration with patients, families, and healthcare providers.

Coordinate services across primary care, specialty care, behavioral health, and community resources.

Collaborates with care teams to optimize individualized care plans for improved health outcomes.

Provide transition care for patients discharged from the hospital within 24-48 hours to prevent readmission.

Perform RN Care Management tasks, including comprehensive assessment, care coordination, disease education, and care plan creation. Patient Education & Advocacy

Educate patients and caregivers on disease management, medication adherence, and lifestyle modifications.

Identify care gaps and initiate appropriate tests, labs, or referrals. Educate and schedule patients as needed.

Empower patients to actively participate in their care and navigate the healthcare system effectively. Interdisciplinary Collaboration

Serve as a liaison between patients, providers, and community organizations.

Participate in case conferences, care team huddles, and multidisciplinary rounds. Documentation & Compliance

Maintain accurate and timely documentation in accordance with regulatory and organizational standards.

Ensure compliance with HIPAA and other relevant healthcare regulations.

Review medical records for compliance, quality monitoring, data collection, and patient care coordination.

Maintain licensure and fulfill educational requirements for special programs.

Attend required training sessions.

Ensure open communication regarding patient status with providers and office staff.

Train other practice staff as needed.

Perform other duties as assigned by the supervisor. Qualifications:

Education and Experience:

Registered Nurse (RN) with a valid South Carolina license.

Minimum of three (3) years of nursing experience.

Preferred experience in care management and quality navigator roles.

Preferred experience in HEDIS, quality and value-based care.

BSN preferred.

BLS certification required. Knowledge, Skills, and Abilities:

Team-oriented with effective communication skills.

Ability to record patient data and communicate with providers.

Adaptable to the changing needs of the health center.

Capable of working independently and collaboratively.

Highly organized and detail-oriented.

Sound judgment and decision-making abilities.

Excellent interpersonal and written/verbal communication skills.

Maintain confidentiality in accordance with health center policies and regulations.

Proficient in Microsoft Word, Excel, Electronic Health Records, and web-based applications.

Ability to learn new computer programs.

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