LPN​/RN Nurse Care Manager - PCHH

To support the continued delivery of quality and compassionate care in our communities, we are offering a retention bonus of $4,000 for Nurses.
* Your commitment helps us meet critical service needs, and we’re excited to have you be a part of our mission!

Deliver Whole-Person Care as a Nurse Care Manager – Primary Care Health Care Home

Schedule:

Monday - Friday, 40 hours weekly.

Do you believe in the power of integrated care to transform lives? As a  Nurse Care Manager  in our  Primary Care Health Care Home  department, you’ll play a key role in supporting individuals with co-occurring medical and behavioral health needs through a person-centered, whole-health approach. This position combines hands-on clinical care with collaborative care coordination—ensuring our patients have the support they need to achieve better health outcomes.

This is a great opportunity for someone  who thrives in a fast-paced, team-oriented primary care setting and is passionate about making a meaningful impact on health equity and chronic disease management in underserved communities.

Key Responsibilities
Manage a caseload of up to 250 Health Care Home patients
Complete annual care plans and ongoing monitoring of patients’ medical needs
Develop and support health-related treatment plan goals for patients with chronic conditions
Provide client education on health conditions, medications, prevention, and self-care
Collaborate with primary care providers, care teams, and specialists to coordinate comprehensive care
Monitor patient records, reports, and alerts (e.g., hospital admissions, medication needs) using HIT tools and EMRs
Perform medication reconciliations after hospital discharges and assist with follow-up care
Analyze data and trends (e.g., DRVS reports) and contribute to performance improvement efforts
Support documentation and tracking of Uniform Data System (UDS) quality measures
Serve as a clinical resource for patients, staff, and care team members
Participate in multi-disciplinary team meetings and contribute to holistic care planning
Seek and provide culturally responsive services to meet individual and family needs
Report to the Regional Primary Care Nursing Director for clinical supervision and support
Requirements, Skills, Knowledge and Expertise
High School/GED required
Practical Nursing or Associate of Nursing degree required
Bachelor’s degree in nursing preferred
Work Experience/Training/

Additional Requirements:

Proficiency in Microsoft Office Suite and Electronic Medical Records preferred

Licensure/Certification :
Licensed Practical Nurse (LPN) or Registered Nurse (RN) required

You’ll Be A Great Fit for This Role if You:
Are passionate about person-centered care and chronic disease management
Feel confident navigating both primary care and behavioral health systems
Excel in team-based settings and value collaboration with other providers
Stay organized and detail-oriented in fast-paced clinical environments
Are proactive in using data and health IT tools to drive patient outcomes
Believe that integrated care is essential for promoting long-term wellness

* Retention bonuses paid as per bonus policy; exclusions may apply.

IND2