Nurse Care Manager

Description

What You'll Do

• 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 panels by closing preventive and chronic care gaps while improving performance on quality and value-based care measures.

• Lead transitional care management, ensuring smooth hospital-to-home transitions through timely outreach, medication reconciliation, and follow-up care.
• Partner with primary care, behavioral health, and interdisciplinary teams to deliver coordinated, integrated care.
• Facilitate case conferences and treatment planning to support shared patients and optimize outcomes.

• Proactively engage patients through outreach and coaching strategies that improve adherence, self-management, and health literacy.
• Address social determinants of health by connecting patients to internal and community-based resources that remove barriers to care.
• Use motivational interviewing and culturally responsive communication to build trust and drive meaningful behavior change.

• Conduct ongoing assessments and adjust care plans based on patient condition, risk, and utilization patterns.
• Monitor hospital utilization trends and implement targeted interventions to reduce avoidable admissions.
• Ensure accurate, compliant documentation that supports quality reporting, regulatory requirements, and value-based care initiatives such as MSSP and payer contracts.

• Serve as a key liaison across providers, community partners, and programs to ensure seamless, integrated service delivery.
• Participate in interdisciplinary meetings and organizational initiatives to improve population health and patient experience.
• Provide clinical support, including direct RN functions as needed, to ensure continuity and excellence in care delivery.

Required Credentials & Experience

• 
  A minimum of an Associate’s Degree in Nursing.
• Active Registered Nurse (RN) licensure in the State of Rhode Island.
• Minimum of two (2) years of experience in community health, primary care, acute care, or care management involving coordination of complex patient needs.
• Demonstrated experience managing high-risk or medically complex patient populations and coordinating interdisciplinary care.

• Demonstrates strong clinical judgment and prioritization skills to manage complex patient needs in a fast-paced environment.
• Applies accountability and data-driven decision-making to achieve measurable outcomes in population health and quality performance.
• Builds effective partnerships across interdisciplinary teams and external organizations to coordinate comprehensive care.
• Communicates clearly and effectively with diverse patient populations, adapting approach to support understanding and engagement.
• Maintains high standards of organization, documentation accuracy, and follow-through on care plans and patient needs.
• Shows adaptability and resilience in managing changing priorities, patient needs, and organizational requirements.

• Experience working within a Patient-Centered Medical Home (PCMH) or value-based care environment.
• Familiarity with Accountable Entity programs, MSSP, or other payer-based quality initiatives.
• Knowledge of population health tools and electronic health record (EHR) systems used for care management and reporting.

Benefits

• Subsidized, comprehensive medical (BCBSRI) and dental (Delta Dental) insurance plans
• Supplemental vision insurance (Delta Dental)
• Voluntary medical and dependent care flexible spending accounts
• Up to 3% matching 403(b) retirement plan
• Employer-paid life insurance
• Generous paid time off including vacation, holidays, personal days, and sick time
• Mileage reimbursement
• Tuition reimbursement
• Employer-paid professional development
• Employee assistance program

About East Bay Community Action Program