Nurse Care Manager

Over the past 30+ years, Rhode Island Primary Care Physician’s Corporation (RIPCPC) has grown to become the largest independent provider association of primary and pediatric care in the state, delivering exceptional care to over 200,000 Rhode Islanders. RIPCPC delivers support services that are essential to providing high quality, cost-effective medicine to patients, while also preserving community-based practices. In 2023, RIPCPC joined Akido Labs , becoming a key east coast hub for healthcare innovation within the Akido Care medical network.

Akido Care’s fast-growing medical network is known for its ability to integrate innovative technology into the healthcare infrastructure, relieving the frustrations felt by everyone involved in care delivery, from medical providers and their staff, to the patients and their families.

We're building a dynamic, diverse and driven team as we continue to grow and broaden our impact. We are seeking passionate people who care deeply about helping patients and communities. We hope you’ll join our team!

Under the supervision of the Nursing manager the Nurse Care Manager-CCM ( NCM ) is responsible to evaluate and provide case management services for patients with complex medical and social needs. The NCM will have the opportunity to work on a multidisciplinary healthcare team in a primary care setting, including but not limited to the primary care provider, pharmacist, community health worker and the behavioral health specialist.

The NCM is responsible for providing comprehensive screenings, assessment, care coordination services, disease education, and culturally sensitive, patient centered self-management support to patients with targeted chronic health conditions. The NCM will be integrated into the office-based healthcare team to promote patient-centered care, will have frequent contact with primary care providers and medical home team members, actively participate in multidisciplinary patient-centered care and team meetings.

• Retrieve monthly high-risk list and proactively outreach to enroll patients in complex case management
• Collaborate with Primary Care Physician (PCP) to prioritize patients identified for complex case management.
• Coordinate with the PCP office to leverage any opportunity to meet with a patient face to face before, during or after a regularly scheduled visit.
• Conduct home visits as necessary.
• Conduct a comprehensive assessment to evaluate a patient’s physical, functional, social, psychological, environmental, learning and financial needs.
• Identify and prioritize problems, goals and interventions designed to meet patient’s need and that consider the patient/caregivers goals, preferences and desired level of involvement in the case management plan.
• Create a patient centered care plan including goals, self-management goals, and interventions designed to address findings from the comprehensive assessment which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the patient. Utilize interpreter services as needed.
• Provide education, information, direction and support related to care goals of patients as well as disease prevention and health promotion
• Implement and monitor the care plan to ensure the effectiveness and appropriateness of services, and adjust as needed
• Communicate on a regular basis (per established program requirements ( ex . NCQA) ) to evaluate patient’s progress toward goal achievement, including identification and evaluation of barriers to meeting or complying with case management plan of care, and systematically reassess for changes in goals and/or health status, and appropriateness for discharge.
• Support a patient’s transition between healthcare facilities by communicating with onsite case managers/ discharge planners and sharing current care management plans to facilitate care coordination, continuity of care and to avoid unnecessary readmissions.
• Critically evaluate case management plan and consider/implement innovative and customized options to help patients achieve goals as needed.
• Initiate…