RN Care Manager in Outpatient Family Medicine

Description

• Non-exempt/Hourly
• Standard wage range is $40.25 to $49.32 per hour
• It may be possible to earn more over time up to $58.33 per hour
• Eligible for a Saturday shift differential

• 40 hours per week
• Shifts available for four 10-hour days or five 8-hour days Monday-Friday
• Participation in Saturday rotation with schedule of 10am-3:00pm
• Shifts may change occasionally based on patient access and organizational needs

Unity Care NW is a private, non-profit, federally qualified health center (FQHC) that has been proudly and successfully serving the greater Whatcom County area since 1982. With clinics located in Bellingham & Ferndale, we offer comprehensive primary medical, behavioral health and dental care, as well as pharmacy services to a diverse and often underserved patient population of all ages. Employing more than 300 caring and compassionate employees, our mission is to increase the years of healthy life in the people & communities we serve.

• Respect
• Integrity
• Accountability
• Collaboration
• Innovation

We strive to demonstrate our Values in Action in all that we do. We value each individual on our team and aim to onboard a workforce of the very best talent, whose ambitions and values align with ours.

The RN Care Manager is responsible for providing proactive, population-based, patient-centered care management to a defined panel of patients within a team-based primary care model. This role focuses on chronic disease management, preventive care gap closure, transitions of care, and patient self-management support. The primary duties and responsibilities include:

1. Panel Management & Care Coordination

a. Performs direct patient care and RN-driven care management for empaneled patients from prioritized patient populations.

b. Collaborates with Medical Leadership in identifying priority populations and defining entry and exclusion criteria.

c. Conducts proactive and regular outreach using registries, reports, and risk stratification tools

d. Coordinates care across the care team, including providers, MAs, behavioral health, pharmacy, case management, referrals, and external partners

e. Keeps patients’ primary care provider informed on progress, needs and potential barriers

f. Serves as consistent point of contact for patients enrolled in care management

2. Chronic Disease & Preventive Care Management for empaneled patients

a. Enrolls eligible patients in and discharges patients from care management based on established criteria

b. Monitors disease-specific outcomes (e.g. blood pressure, HbA1c) and intervenes using approved protocols and standing orders

c. Identifies and closes preventive care gaps (e.g. screenings, labs, immunizations)

d. Provides patient education, coaching, and goal setting using motivational interviewing techniques

3. Transitions of Care for patients enrolled in Care Management:

a. Completes hospital and emergency department follow-up outreach within established timelines

b. Performs medication reconciliation and symptom assessment post-discharge

c. Coordinates follow up appointments, labs, and referrals to reduce readmissions and care fragmentation

4. Care Planning & Documentation

a. Develops and maintains individual, person-centered care plans in collaboration with patients and providers

b. Screens for social drivers of health, depression, anxiety, and barriers to care

c. Ensures all care plans include targeted completion dates and timelines for monitoring and follow-up

d. Meets with patients in accordance with their care plan and documents all care management activities accurately and timely in electronic health record

e. Uses standardized documentation tools, templates, and workflows consistent with Patient Centered Medical Home requirements

5. Quality & Program Development:

a. Participates in quality improvement initiatives and supports achievement of quality goals related to care management

b. Plays a lead role in the development and refinement of RN care management protocols and workflows

c. Tracks and reports care management metrics as assigned

d. Collaborates with leadership to evaluate program effectiveness and opportunities for expansion