Care Manager Registered Nurse

About Hopscotch Primary Care At Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities. Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities. We are on a mission to transform healthcare in rural America. We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most. Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch. Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time. Today, we are serving thousands of patients in our value-based care model and the number is growing every day. If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we’d like to meet you. ABOUT THE ROLE The Care Manager Registered Nurse (CMRN) is a hybrid role responsible for managing a panelofhigher-acuitypatients (HPP)through a combination ofprimarily remote case management and targeted in‑clinic support, such asHigh‑RiskHuddle meetings . This role is accountable for end-to-end care management, with a strong focus on: Reducingavoidable admissions (ADK)andemergency departmentutilization(EDK) Improving clinical outcomes and patient experience Supporting care continuity across the healthcare continuum The CMRN partners closely withproviders, clinic staff, and Care Center Managers (CCMs)to deliver coordinated, proactive, and patient-centered care. This position is primarily remote, withregular in-office presencebased on patient or programneeds. Specific responsibilities for this role will include, but are not limited to: Panel Management & Care Coordination (Primarily– Remote) Manage a defined panelofhigh-risk patients, delivering comprehensive, longitudinal case management Develop, implement, and continuously update individualizedcare plansin collaboration with providers and care teams Perform ongoingtelephonicoutreachand monitoringto improve patient outcomes Coordinate care acrossthe patients HPC provider, specialists, hospitals, EDs, SNFs, and community resources Partner and collaborate withtransitions of careteam,for a smooth transition and to ensurethatthe patient needsare met following the transitions of care period Clinical Collaboration & Outcomes Management Partner withproviders, MAs, LPNs, andCare Center Managersto align on patient care plans and priorities Escalate clinical concerns and barriers to care in real time Participate in team huddles, case reviews, and interdisciplinary care discussions Track and improvequality andutilizationmetricstied to patient outcomes In-Clinic Responsibilities (Hybrid Component) Maintainin-office presenceminimum of 1 time a monthandas neededto: Support high-risk patient visits Assistwith care coordination for complex patients Home & Community-Based Support Coordinate with in office LPN foroccasional home visitsfor high-risk or complex patients when clinicallyappropriate Assesssocial determinants of health, home safety, and barriers to care Coordinate community-based services and resources to supportpatientcare plangoals Patient & Family Engagement Build trusted relationships with patients, families, and caregivers Provide education ondisease management, medications, and care plans Utilizemotivational interviewing and coaching techniquesto drive behavior change Program Quality, Compliance & Best Practices Adhere to care management protocols, regulatory requirements, and documentation standards Support continuous improvement of care management workflows and outcomes Identifyand reportgaps, risks, or adverse events Contribute to development ofbest practices, training, and process improvements ABOUT YOU You would be a great fit for this position if you have a minimum of2years of experience as acare manager embedded into an interdisciplinary team and the following: Active registered nurse (RN) license in North Carolina BLS certification Experienceworking in a primary careclinicfocused on chronic disease management Experience withbehavioralhealth and community-based organizationspreferred Experience with motivational interviewing, behavior change, health promotion, and coaching Strong verbal and written communication skills and customer service orientation From a cultural perspective, you are: Patient-first, team-oriented Agile and thoughtful in a fast-paced environment Solutions-driven, always looking to improve Accountable, withhigh standardsfor yourself and others Hands-on and collaborative across diverse teams Clear, concise communicator who follows through Positive, assuming good intent Customer-focused, with a passion for serving patients and providers At Hopscotch Primary Care, we embrace diversity, invest in a culture of inclusion and positivity and encourage all to apply to join our team. You will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. #J-18808-Ljbffr Hopscotch Primary Care