Nurse Care Manager - General Medicine & Geriatrics

Nurse Care Manager

The Nurse Care Manager provides expert care coordination within a dynamic, multi-site outpatient environment, moving away from bedside burnout into a relationship-based model that prioritizes long-term patient impact. Schedule: MondayFriday | 8:00 am 4:30 pm. Work life balance: No weekends, no holidays, and no on-call. Variety: A hybrid rotation across our premier CAM, West County, and Sunset Hills clinics. The Nurse Care Manager acts as a clinical anchor by coordinating high-risk interventions, bridging care transitions, and fostering provider-patient partnerships to resolve health hurdles and improve patient quality of life.

Primary Duties & Responsibilities:

Care Coordination & Clinical Support

• Serve as the primary point of contact for medically and socially complex patients and their caregivers.
• Coordinate care across primary care, specialty clinics, home health, rehabilitation facilities, and community partners.
• Facilitate transitions of care (hospital ? home, rehab ? outpatient, assisted living, long-term care, hospice).
• Monitor chronic disease management (e.g., dementia, frailty, CHF, COPD, diabetes) and identify early signs of decompensation.
• Review and triage incoming clinical messages and calls related to care coordination, patient needs or concerns requiring follow-up.
• Conduct routine check-ins in all clinic locations to support providers, staff, and patients, ensuring timely response to questions and identification of emerging patient needs.

Patient Assessment & Care Planning

• Conduct comprehensive geriatric assessments addressing medical, functional, cognitive, psychosocial, and environmental needs.
• Develop individualized care plans in collaboration with providers and the interdisciplinary team, incorporating Age-Friendly Health System principles (What Matters, Medication, Mentation, Mobility).
• Identify gaps in care, medication concerns, fall risks, cognitive decline, and safety risks; escalate appropriately.
• Support patients and caregivers managing chronic conditions by reinforcing care plans, educating on self-management, and helping navigate complex care systems.

Social Support & Resource Navigation

• Assess and address social determinants of health impacting older adult outcomes (transportation, caregiving strain, financial barriers, food insecurity, isolation).
• Connect patients and caregivers with community resources, caregiver supports, and state/local services.
• Assist with long-term care planning, home health needs, durable medical equipment, and referrals to senior services or palliative care.
• Advocate for patients and families to ensure access to appropriate services and supports.

Communication & Collaboration

• Maintain close communication with providers about patient needs, care barriers, and changes in condition.
• Collaborate with social work, nursing, pharmacy, therapy services, and community agencies.
• Participate in interdisciplinary team meetings, including GAC IDT meetings and case reviews, to discuss complex patients and adjust care strategies.
• Provide guidance and support to caregivers navigating dementia, functional decline, or other patient specific challenges.

Advocacy & Patient Support

• Serve as an advocate for patients and families navigating complex medical and social systems.
• Support caregivers managing stress, burnout, and complex care responsibilities.
• Assist with insurance or coverage questions within the scope of nursing practice.

Documentation & Compliance

• Document all care coordination activities, assessments, care plans, follow-up calls, and resource referrals in the EMR.
• Track patient progress, outstanding care needs, and follow-up items.
• Ensure communication and follow-up comply with clinic protocols, state requirements, and organizational policies.
• Identify safety concerns (e.g., potential elder abuse or neglect) and escalate per mandatory reporting guidelines.

Education & Problem-Solving

• Provide patient and caregiver education on medications, disease processes, self-management strategies, and available resources.
• Independently research resources, troubleshoot barriers to care, and develop patient-centered solutions.
• Support staff education on geriatric-specific issues, social determinants of health, and interdisciplinary care coordination.

Working Conditions:

Job Location/Working Conditions

• Normal office environment.
• Exposure to blood-borne pathogens.
• Patient care setting.
• Direct patient care setting.

Physical Effort

• Typically sitting at desk or table.
• Typically standing or walking.
• Typically bending, crouching, stooping.
• Occasional lifting (>25 lbs).

Equipment

• Requires protective devices.
• Office equipment.
• Clinical/diagnostic equipment.

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all job duties performed by the personnel so classified. Management reserves the right to revise or amend duties at any time.

Required Qualifications:

• Registered Nurse in the state of Missouri or Illinois.
• Basic Life Support certification (Online BLS certifications, those without a skills assessment component, are not sufficient to meet the BLS requirements).

Salary Range

$64,500.00 - $109,900.00 / AnnuallyThe salary range reflects base salaries paid for positions in a given job grade across the University. Individual rates within the range will be determined by factors including one's qualifications and performance, equity with others in the department, market rates for positions within the same grade and department budget.