Nurse Care Manager

Nurse Care Manager

Department:
Medical

Employment Type:

Full Time

Location:

Newport - Chafee Medical

Reporting To:
Director of Nursing

Description

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.

What You'll Do

Lead High-Impact Care 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.

Drive Care Coordination & Transitions

* 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.

Engage Patients & Address Whole-Person Needs

* 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.

Strengthen Quality, Compliance & Outcomes

* 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.

Collaborate & Contribute Across the Organization

* 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.

Required Credentials & Experience

* 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.

Core Competencies

* 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 adaptability and resilience in managing changing priorities, patient needs, and organizational requirements.

Preferred Qualifications

* Experience working within a Patient-Centered Medical Home (PCMH) or value-based care environment.

* Familiarity with Accountable Entity programs, MSSP, or other payer-based quality initiatives.

* Knowledge of population health tools and electronic health record (EHR) systems used for care management and reporting.

Benefits

For Full-Time Employees Working 30-40 hours per week, EBCAP offers:

* Subsidized, comprehensive medical (BCBSRI) and dental (Delta Dental) insurance plans

* Supplemental vision insurance (Delta Dental)

* Voluntary medical and dependent care flexible spending accounts

* Up to 3% matching 403(b) retirement plan

* Employer-paid life…