RN Care Manager

Identify patients who meet criteria for the care management program Review charts to assign acuity levels and assign patients to the appropriate care team Provide oversight to Care Coordinators completing comprehensive assessments and developing individualized care plans Develop and update care plans in collaboration with patients, PCPs, and the care team Support transitions of care, including medication reconciliation, follow-up, specialist referrals, barriers to care, and education Coordinate communication with community partners such as hospitals, emergency departments, and discharge planners Support PCMH implementation and help teams understand care coordination workflows Monitor outcomes, identify gaps, and recommend improvements Coordinate care for patients with multiple chronic conditions as part of a multidisciplinary population-management team Requirements Graduate of an accredited RN program Current North Carolina RN License 2+ years of experience in primary healthcare, ambulatory care and/or home health within the last 5 years High school diploma or GED Comfortable navigating an electronic health record (EHR) Valid North Carolina driver's license and clean driving record, approved for driving privileges Experience with underserved or rural populations preferred Spanish speaking preferred, not required Compassionate, organized, and clinically strong Passion for coordinating care for patients living with multiple chronic conditions Core Competencies Demonstrates expertise in care coordination for patients with multiple chronic conditions, including developing and updating individualized care plans, conducting comprehensive assessments, and collaborating with multidisciplinary teams. Proficient in navigating electronic health records and supporting transitions of care while ensuring effective communication with community partners. Highest-signal resume keywords Registered Nurse (RN) Care Coordination Electronic Health Record (EHR) Navigation Patient Care Management Spanish Speaking Hard Skills Comprehensive Assessments Individualized Care Plans Medication Reconciliation Chronic Condition Management Acuity Level Assignment Soft Skills Compassionate Organized Clinically Strong Certifications & Qualifications North Carolina RN License Industry Keywords Primary Healthcare Ambulatory Care Home Health PCMH Implementation Underserved Populations #J-18808-Ljbffr