RN Care Manager

Manage high-risk and chronic illness to promote whole-person, integrated, quality care Partner with patients, families/caregivers, providers, specialty providers, staff, and community resources Conduct in-office patient visits according to care plans and patient needs Create and promote patient-centered care plans Support integrated care in family medicine, recovery, and psychiatric care Engage patients in self-management and shared decision-making Increase preventive-care utilization and reduce emergency-room use and hospital readmissions Manage tertiary-care relationships, transitions of care, and referrals Coordinate schedules and access to internal and specialty providers Facilitate medical, specialty, residential, and detox referrals Identify high-risk patients, coordinate care, and track outcomes Assess social drivers of health and collaborate with Community Health Workers Attend Care Management training, webinars, and meetings; contribute to program development Participate in quality improvement using dashboards and tracking tools; provide monthly quality reports Follow chronic-care protocols, clinical guidelines, policies, and procedures Perform in-clinic triage and medication refills Conduct nursing assessments to determine needed services and level of care Assist with inductions under provider direction, administer injections, and educate patients on naloxone Monitor OB clients and provide education about Neonatal Abstinence Syndrome and support systems Educate patients about substance use, tobacco cessation, prevention, communicable disease management, and new diagnoses Monitor medication adherence, check the PDMP, monitor side effects, provide education, assist with prior authorizations and prescription assistance Perform medication reconciliation and refill requests, including controlled substances under provider direction and approval Connect patients with community resources to improve health, satisfaction, and healthcare costs Serve as contact point, advocate, and informational resource for patients, care teams, families, payers, and community resources Facilitate meetings among patients, families/caregivers, care teams, and community resources Requirements Candidates must reside within NorthLakes' service area at the time of hire and maintain residency throughout employment Associates Degree in Nursing RN with two+ years related experience and/or training Experience with Electronic Health Records, preferably Epic Current, valid and unrestricted WI license to practice as a Registered Nurse Current CPR certification required Evidence of leadership, communication, education and counseling skills Local knowledge about community health care and social welfare resources preferred Successful completion of a criminal background check and references Core Competencies Demonstrates expertise in managing high-risk and chronic illness through patient-centered care plans, effective communication, and collaboration with community resources. Proficient in utilizing Electronic Health Records and adhering to clinical guidelines to improve patient outcomes and satisfaction. Highest-signal resume keywords Registered Nurse (RN) Electronic Health Records (EHR) Patient-Centered Care Plans Chronic-Care Protocols CPR Certification Hard Skills Nursing Assessments Medication Reconciliation Care Coordination Patient Education Triage Procedures Substance Use Education Community Resource Connection Quality Improvement Outcome Tracking Referral Management Soft Skills Leadership Skills Communication Skills Counseling Skills Advocacy Collaboration Certifications & Qualifications WI RN License CPR Certification Industry Keywords Chronic Illness Management Integrated Care Preventive Care Community Health Social Drivers of Health Tools & Technologies Epic EHR Dashboards Tracking Tools #J-18808-Ljbffr