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 insurance
- Generous paid time off including vacation, holidays, personal days, and sick time
- Mileage reimbursement
- Tuition reimbursement
- Employer-paid professional development
- Employee assistance program