Registered Nurse - Care Manager (Full-time, Monday-Friday)

Organization Overview, Mission, Vision, and ValuesOur mission is to improve the health of people in the communities we serve through compassionate, high-quality care, prevention, and wellness education. Washington Regional Medical System is a community-owned, locally governed, non-profit health care system located in Northwest Arkansas in the heart of Fayetteville, which is consistently ranked among the Best Places to live in the country. Our 425-bed medical center has been named the #1 hospital in Arkansas for five consecutive years by U.S. News & World Report. We employ 3,200+ team members and serve the region with over 40 clinic locations, the region’s only Level II trauma center, and five Centers of Excellence - the Washington Regional J.B. Hunt Transport Services Neuroscience Institute; Washington Regional Walker Heart Institute; Washington Regional Women and Infants Center; Washington Regional Total Joint Center; and Washington Regional Pat Walker Center for Seniors.Position SummaryThe Care Manager (CM) supports patients across the care continuum by performing nurse-led Medicare Annual Wellness Visits (AWVs), providing case management and complex care management, and driving enrollment in Advanced Primary Care Management (APCM). This role works closely with providers and clinical operations to close care gaps, improve quality outcomes, and support patients with chronic and complex needs in a value-based care environment. The CM operates within Epic and other care management platforms to document, track, and coordinate patient care activities.Essential Position ResponsibilitiesNurse-Led Medicare Annual Wellness Visits (AWV)Independently perform nurse-led AWVs under applicable state scope of practice and CMS direct supervision requirementsConduct the full AWV visit, including Health Risk Assessments (HRAs), cognitive screenings, functional/safety screenings, and development of a personalized prevention planReview and reconcile medication lists, screening histories, and immunization status with the patientDocument the visit to meet CMS requirements for AWV billing (G0438/G0439)Identify and close associated quality measure gaps during the visit, per established protocolsEscalate any clinical concerns to the supervising provider for review and sign-offCase ManagementConduct patient assessments to identify medical, behavioral, and social needsCoordinate referrals to community resources.APCM EnrollmentIdentify patients eligible for Advanced Primary Care Management based on CMS risk stratification criteriaEducate patients and caregivers on APCM program benefits and obtain consent for enrollmentCoordinate with billing/compliance staff to ensure documentation supports appropriate service level.Complex Care ManagementManage a caseload of patients with multiple chronic conditions, high utilization, or elevated risk scoresDevelop and maintain individualized care plans in collaboration with the care teamPerform regular outreach (telephonic, MyChart, in-person) to monitor status and reinforce care plansProvide patient and caregiver education on diagnoses, treatment plans, and self-managementCollaborate with interdisciplinary team members on complex casesEscalate urgent clinical concerns per established protocolsDocumentation & QualityMaintain accurate, timely documentation in Epic consistent with organizational and regulatory standardsSupport HEDIS and other quality measure compliance through accurate coding and gap closure documentationParticipate in quality improvement initiatives and case reviewsTrack and report on productivity and outcome metrics as defined by leadershipQualificationsRequiredCurrent, unencumbered RN license in the state of ArkansasMinimum 2 years of clinical experience in primary care, case management, or care coordinationStrong understanding of Medicare AWV, CCM, and/or APCM program requirementsProficiency with EHR systems (Epic preferred)Excellent communication, organization, and interpersonal skillsPreferredExperience in a value-based care or ACO environmentFamiliarity with HEDIS quality measuresCase Management certification (CCM) or willingness to obtain within a defined timeframeExperience with population health/risk stratification toolsCore CompetenciesPatient-centered communication and motivational interviewingTime management across a mixed caseload (scheduled visits, telephonic outreach, documentation)Critical thinking and clinical judgment for escalation decisionsCollaborative, team-based approach to care deliveryComfort with data tracking and quality metric reportingWork Environment: This role requires a combination of clinical and office-based activity. The position may involve extended periods of standing and walking, as well as occasional pushing, pulling, lifting, or carrying materials up to 50 pounds. The role also includes time spent sitting and working in a standard office environment. Depending on the care setting, the position may be exposed to communicable diseases, bodily fluids, and other typical healthcare workplace conditions. This position serves a culturally and linguistically diverse patient population.Notice: This job description is designed to provide an overview of the essential and principal duties and responsibilities of the position. The job description is not designed or intended to cover or set forth a comprehensive listing of all activities, duties or responsibilities that are required of the employee. Washington Regional reserves the right in its absolute discretion to change duties, responsibilities or activities or assign new duties, responsibilities, or activities at any time with or without notice. Employees may be directed to perform job-related tasks other than those specifically presented in this description. #J-18808-Ljbffr Washington-Regional-Medical-Center