RN Care Manager Advanced Primary Care Geauga

Job Description – RN Care Manager Advanced Primary Care Geauga ) A Brief Overview

Under general supervision of the Supervisor, APC Care Management, the APC Administrator and the Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), the RN Care Manager performs as a member of the healthcare team to apply the nursing process when making nursing judgments and decisions specific to assessment, planning, implementation/delivery, and evaluation of patient care, and documenting relevant data and care processes.

The RN Care Manager facilitates communication between the patients and their Primary Care Providers and assists with chronic disease action plans, transitional care management, Advance Directives planning, Annual Wellness Visits, and preventative care utilizing assessment skills both in person and telephonically. This RN position is a resource for other team members and requires critical thinking skills.

• Exercise professional nursing judgment appropriate to the level of care needed, prioritizing patient acuity and workload demands. The RN Care Manager functions with greater autonomy by consistently demonstrating independent clinical decision‑making abilities.
• Provide patient care that demonstrates nursing knowledge and technical competence; recognize significant changes in patients’ condition/situation and take appropriate action. Communicate with patients/families, including relaying physician orders and changes in the plan of care.
• Assist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with rules, regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family.
• Work as a leader in the Advanced Care Model in ambulatory practice and collaborate with the APC Administrator and Director of APP & UHPS Nursing to drive system‑wide initiatives and changes.
• Integrate RN care management into the Primary Care office responsible for managing patients’ care across the continuum.
• Analyze sources of data to identify high‑risk patients and member groups.
• Manage high‑risk patients, including those with multiple comorbidities or at high risk for readmission.
• Develop longitudinal care planning that includes assessment, planning, implementation, and monitoring.
• Coordinate continuity of care with patients and families following hospital admission, discharge, and ER visits.
• Advocate for patients by assisting in navigation of the health system.
• Communicate the patient’s goals and progress to the care team.
• Participate in quality improvement initiatives.
• Participate in data collection to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement.
• Provide one‑on‑one office visits for patients to implement care planning.
• Provide health and disease education to patients and families, including group education opportunities.
• Support patients in self‑management of their disease and behavior modification interventions.
• As a member of the community care team, identify appropriate resources—including specialists, facilities, and external healthcare organization supports—to provide an interdisciplinary approach.
• Collaborate with office staff in the coordination of individual patient care needs.
• Support and facilitate advanced care planning for patients and their families.
• Demonstrate proficiency and act as an expert role model in the performance of patient care.

• Perform other duties as assigned.
• Comply with all policies and standards.
• Refer to documentation provided by the department during orientation for specific duties and responsibilities.
• Abide by all requirements to safely and securely maintain Protected Health Information (PHI) for patients. Annual training, the UH Code of Conduct and UH policies and procedures address appropriate use of PHI in the workplace.

• Graduate of an accredited school of nursing (Required).
• Bachelor’s Degree (Preferred).

• 3+ years of clinical experience (Required).
• 1+ year in the outpatient, ED, or urgent care setting (Preferred).
• Experience working with…