Nurse Care Manager - General Medicine & Geriatrics

Position Summary 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: Monday–Friday 8:00 am – 4:30 pm. Work life balance: No weekends, no holidays, and no on‑call. Variety: A hybrid rotation across 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. Scheduled Hours 40 hours per week. 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 – Normal office environment; exposure to blood‑borne pathogens; patient care setting; direct patient care setting. Physical Effort – Typically sitting at desk or table; standing or walking; bending, crouching, stooping; occasional lifting (>25 lbs). Equipment – Requires protective devices; office equipment; clinical/diagnostic equipment. Education and Qualifications Required: Bachelor’s degree. Required Licensure and Certification: Registered Nurse in the state of Missouri or Illinois. Basic Life Support certification (online BLS with skills assessment). No specific work experience is required. Skills not applicable in the traditional sense, but preferred skills include: Adult Health Nursing, Ambulatory Care, Clinical Patient Care, Confidentiality, Data Analysis, Delegation Management, Electronic Medical Record (EMR) Software, Emergency Training, Epic EHR, Leadership, Managed Care, Medical Triage, Nursing Fundamentals, Oral Communications, Patient Care Plans, Patient Management, Research Management, Software Platforms, Strategy Implementation, Written Communication. Driver’s license is not required. Grade: S26. Salary Range: $60,800.00 – $105,700.00 per year. Benefits Statement Up to 22 days of vacation, 10 recognized holidays, and sick time. Competitive health insurance packages with priority appointments and lower copays/coinsurance. Free Metro transit U‑Pass for eligible employees. Defined contribution (403(b)) retirement savings plan with employee and university contributions starting at 7%. Wellness challenges, annual health screenings, mental health resources, mindfulness programs, employee assistance program, financial resources, access to dietitians. 4 weeks of caregiver leave to bond with a new child; family care resources for continued childcare needs. Tuition support for employees and their families (up to 100% at WashU and 40% elsewhere after seven years). EEO Statement Washington University in St. Louis is committed to the principles and practices of equal employment opportunity. It is the University’s policy to provide equal opportunity and access to persons in all job titles without regard to race, ethnicity, color, national origin, citizenship, age, religion, sex, sexual orientation, gender identity or expression, disability, protected veteran status, or genetic information. #J-18808-Ljbffr Washington University in St. Louis