Nurse Care Manager

Nurse Care Manager

Department: Medical

Employment Type: Full Time

Location: Newport - Chafee Medical

Reporting To: Director of Nursing

The Nurse RN Care Manager provides comprehensive clinical care management, chronic disease support, transitional care coordination, patient education, and whole‑person care planning for high‑risk and medically complex patients across medical and behavioral health services. This role supports Patient‑Centered Medical Home (PCMH) standards, value‑based care initiatives, Accountable Entity (AE) requirements, CCBHC integration, and organizational quality goals through interdisciplinary collaboration, proactive outreach, and population health management.

• 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.

This is a dynamic, patient‑centered role where you’ll combine clinical expertise, data‑driven decision‑making, and strong collaboration to make a measurable impact on both individual patients and broader populations.

• 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…