RN Care Manager

• Manage high-risk and chronic illness to promote whole-person, integrated, quality care
• Partner with patients, families/caregivers, providers, specialty providers, staff, and community resources
• Conduct in-office patient visits according to care plans and patient needs
• Create and promote patient-centered care plans
• Support integrated care in family medicine, recovery, and psychiatric care
• Engage patients in self-management and shared decision-making
• Increase preventive-care utilization and reduce emergency-room use and hospital readmissions
• Manage tertiary-care relationships, transitions of care, and referrals
• Coordinate schedules and access to internal and specialty providers
• Facilitate medical, specialty, residential, and detox referrals
• Identify high-risk patients, coordinate care, and track outcomes
• Assess social drivers of health and collaborate with Community Health Workers
• Attend Care Management training, webinars, and meetings; contribute to program development
• Participate in quality improvement using dashboards and tracking tools; provide monthly quality reports
• Follow chronic-care protocols, clinical guidelines, policies, and procedures
• Perform in-clinic triage and medication refills
• Conduct nursing assessments to determine needed services and level of care
• Assist with inductions under provider direction, administer injections, and educate patients on naloxone
• Monitor OB clients and provide education about Neonatal Abstinence Syndrome and support systems
• Educate patients about substance use, tobacco cessation, prevention, communicable disease management, and new diagnoses
• Monitor medication adherence, check the PDMP, monitor side effects, provide education, assist with prior authorizations and prescription assistance
• Perform medication reconciliation and refill requests, including controlled substances under provider direction and approval
• Connect patients with community resources to improve health, satisfaction, and healthcare costs
• Serve as contact point, advocate, and informational resource for patients, care teams, families, payers, and community resources
• Facilitate meetings among patients, families/caregivers, care teams, and community resources

• Candidates must reside within North Lakes' service area at the time of hire and maintain residency throughout employment
• Associates Degree in Nursing
• RN with two+ years related experience and/or training
• Experience with Electronic Health Records, preferably Epic
• Current, valid and unrestricted WI license to practice as a Registered Nurse
• Current CPR certification required
• Evidence of leadership, communication, education and counseling skills
• Local knowledge about community health care and social welfare resources preferred
• Successful completion of a criminal background check and references

Demonstrates expertise in managing high-risk and chronic illness through patient-centered care plans, effective communication, and collaboration with community resources. Proficient in utilizing Electronic Health Records and adhering to clinical guidelines to improve patient outcomes and satisfaction.

• Registered Nurse (RN)
• Electronic Health Records (EHR)
• Patient-Centered Care Plans
• Chronic-Care Protocols
• CPR Certification

• Nursing Assessments
• Medication Reconciliation
• Care Coordination
• Patient Education
• Triage Procedures
• Substance Use Education
• Community Resource Connection
• Quality Improvement
• Outcome Tracking
• Referral Management

• Leadership Skills
• Communication Skills
• Counseling Skills
• Advocacy
• Collaboration

• WI RN License
• CPR Certification

• Chronic Illness Management
• Integrated Care
• Preventive Care
• Community Health
• Social Drivers of Health

• Epic EHR
• Dashboards
• Tracking Tools