Acute Care, Behavioral Health, Case Management, Chronic Disease, Clinical Data, Clinical Medicine, Clinical Support, Coaching, Communication Skills, Community Health, Community Programs, Conference Management, Dental Insurance, Disease Prevention and Control, Documentation Standards, Employee Assistance Plan, Establish Priorities, Follow Through, Health Plan, Healthcare, Hospital, Literacy, Medical Record System, Medications, Nursing, Nursing Management, Patient Care, Patient Education, Performance Management, Preventive Medicine, Primary Care, Process Improvement, Quality Assurance, Quality Management, Reconciliation, Registered Nurse (RN), Regulatory Reports, Regulatory Requirements, Risk, Risk Management, Service Delivery, Standards of Care, Support Documentation, Time Management, Transitional Care, Utilization Management
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