Case Manager, RN

• Coordinate care for high-risk and chronic disease patients to improve health outcomes
• Provide patient education, care coordination, chronic disease management support, transition-of-care services, and population health interventions
• Assist in developing self-management skills and achieving individualized health goals
• Monitor patient progress and identify barriers to treatment adherence and disease management
• Coordinate care between primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community resources
• Conduct outreach and follow-up for patients following emergency department visits, hospitalizations, and other care transitions
• Document patient encounters accurately and timely within the electronic health record
• Promote timely post-discharge follow-up to reduce avoidable readmissions

• Associate degree in Nursing
• Valid Arizona State License as a Registered Nurse
• 3 years’ clinical nursing experience
• Basic Life Support (BLS) certification
• Fingerprint Clearance Card through the Arizona Department of Public Safety (may obtain upon hire)
• Valid Arizona driver’s license with clean driving record and proof of current vehicle insurance
• Bachelor’s degree in Nursing or related field (preferred)
• Certified Diabetes Care and Education Specialist (SDCES) (preferred)
• Experience in care management, case management, population health, chronic care management, or value-based care (preferred)
• Experience working in a Federally Qualified Health Center (FQHC), community health center, or primary care setting (preferred)
• Experience with electronic health records and population health management tools (preferred)
• Bilingual (English/Spanish) (preferred)

Demonstrates expertise in care coordination for high-risk and chronic disease patients, focusing on improving health outcomes through patient education, chronic disease management, and effective communication with healthcare providers. Proficient in utilizing electronic health records for accurate documentation and monitoring patient progress.

• Registered Nurse License
• Clinical Nursing Experience
• Care Management
• Chronic Disease Management
• Bilingual (English/Spanish)

• Patient Education
• Chronic Disease Management
• Care Coordination
• Transition-of-Care Services
• Population Health Interventions

• Communication
• Patient Advocacy
• Problem-Solving

• Basic Life Support (BLS)
• Certified Diabetes Care and Education Specialist (SDCES)
• Fingerprint Clearance Card

• High-Risk Patients
• Chronic Disease
• Value-Based Care
• Federally Qualified Health Center (FQHC)
• Community Health Center

• Electronic Health Records
• Population Health Management Tools