Registered Nurse

Job Description

Staff Nurse Care Manager (Registered Nurse)

Chronic Care Management | Home-Based Primary Care | Full-Time

ABOUT FREEDMEN’S MEDICINE

Freedmen’s Medicine is a home-based primary care practice delivering integrated, whole-person care to homebound adults in the District of Columbia living with complex chronic medical conditions and co occurring behavioral health and substance use disorders. Our interdisciplinary model combines in-home and telehealth primary care with Chronic Care Management (CCM), the Collaborative Care Model (CoCM), Community Health Integration (CHI), Principal Illness Navigation (PIN), Transitional Care Management, a community Safety Net Pharmacy partnership, and a mobile Medications for Opioid Use Disorder (MOUD) program. Health is freedom.

POSITION OVERVIEW

he Staff Nurse Care Manager is a registered nurse lead for chronic care management implementation in support of the home-based primary care team. Working a minimum of 16 hours per week (two days) alongside other staff nurses, including RNs and LPNs, the RN carries an independent patient caseload, shares responsibility with fellow staff nurses for assessments, person-centered care planning, and recommendations to the multidisciplinary care team, directs the day-to-day work of a team of Community Health Workers, and serves as the clinical link between patients, caregivers, medical providers, pharmacy, behavioral health, and community-based service partners. The staff nurses work as a team to address the full range of chronic care management requirements for the medical practice, and each staff nurse operates under the general supervision of the physician or nurse practitioner who serves as the primary care provider for their assigned patients.The position carries responsibility for the full scope of medical case management—care planning and monitoring, medical supply ordering, home- and community-based service coordination, specialist referral management, health education, patient advocacy, and behavior change support—and for translating what the care team learns in the home into actionable recommendations that improve treatment adherence and outcomes

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Chronic Care Management Leadership
• Person-Centered Care Planning and Monitoring
• Medical Case Management and Care Coordination
• Health Education, Advocacy, and Behavior Change
• Treatment Adherence and Provider Recommendations
• Safety Net Pharmacy Program — North Capitol Pharmacy
• Mobile MOUD Program Support
• Community Health Worker Team Management
• Multidisciplinary Care Team Participation
• Documentation, Quality, and Compliance

QUALIFICATIONS

Required

• Active, unrestricted Registered Nurse license valid in the District of Columbia.
• Associate degree or diploma in nursing from an accredited program.
• Minimum of two (2) years of RN experience, including at least one (1) year in care management, home health, community health, primary care, or transitions of care.
• Current Basic Life Support (BLS) certification.
• Demonstrated ability to develop and manage person-centered care plans for adults with multiple chronic conditions.
• Valid driver’s license, acceptable driving record, reliable transportation, and personal automobile insurance meeting Freedmen’s Medicine requirements.
• Proficiency with electronic health records and Microsoft Office.

Preferred

• Bachelor of Science in Nursing (BSN).
• Certified Case Manager (CCM) or ANCC Ambulatory Care Nursing certification — a plus, but not required.
• Experience supervising Community Health Workers or other paraprofessional staff.
• Experience with Medicare CCM, Principal Care Management, CHI/PIN, or Collaborative Care workflows
• Experience caring for persons with substance use disorders, including MOUD and long-acting injectable medications.
• Familiarity with DC Medicaid managed care, long-term services and supports, and the District’s community-based service network.
• Experience with AthenaOne.

KNOWLEDGE, SKILLS, AND ABILITIES

• Clinical judgment in chronic disease management, medication management, and recognition of clinical deterioration.
• Working knowledge of motivational interviewing, trauma-informed care, and harm reduction principles.
• Ability to lead, delegate, and hold team members accountable while fostering a collaborative culture.
• Strong organizational and time-management skills; ability to manage a caseload across office, telephonic, and field settings.
• Clear, respectful communication with patients, caregivers, providers, and community partners from diverse backgrounds.
• Commitment to the confidentiality obligations of HIPAA and 42 CFR Part 2.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

This position combines office-based work with home visits and community-based work throughout the District of Columbia. Home environments vary and may include multi-story walk-ups, limited accessibility, pets, and exposure to tobacco smoke or other environmental conditions. The role requires the ability to drive or travel independently; to stand, walk, climb stairs, bend, and kneel; to lift and carry up to 25 pounds of supplies and equipment; and to sit and work at a computer for extended periods. Reasonable accommodations will be made to enable qualified individuals with disabilities to perform essential functions.

EQUAL OPPORTUNITY STATEMENT

Freedmen’s Medicine is an equal opportunity employer. All qualified applicants and employees will receive consideration without regard to race, color, religion, national origin, sex, sexual orientation, gender identity or expression, age, disability, veteran status, or any other characteristic protected under federal law or the DC Human Rights Act. This job description is not an employment contract; it is intended to describe the general nature and level of work and may be revised as the needs of the practice and our patients evolve. Employment with Freedmen’s Medicine is at-will.