Full time
East Bay Community Action Program (EBCAP)
Newport, RI
Description The Nurse RN Care Manager provides comprehensive clinical care management, chronic disease support, transitional care coordination, patient education, and whole-person care planning for high-risk and medically complex patients across medical and behavioral health services. This role supports Patient-Centered Medical Home (PCMH) standards, value-based care initiatives, Accountable Entity (AE) requirements, CCBHC integration, and organizational quality goals through interdisciplinary collaboration, proactive outreach, and population health management. What You'll Do Lead High-Impact Care Management Identify and prioritize high-risk, high-utilizing patients using population health tools and data to target interventions that reduce preventable hospitalizations and emergency visits. Develop and manage individualized care plans with clear goals, evidence-based interventions, and structured follow-up tailored to each patient’s needs. Manage patient...

