LPN/RN Nurse Care Manager - PCHH

To support the continued delivery of quality and compassionate care in our communities, we are offering a retention bonus of $4,000 for Nurses.* Your commitment helps us meet critical service needs, and we’re excited to have you be a part of our mission! Deliver Whole-Person Care as a Nurse Care Manager – Primary Care Health Care Home Schedule: Monday - Friday, 40 hours weekly. Do you believe in the power of integrated care to transform lives? As a Nurse Care Manager in our Primary Care Health Care Home department, you’ll play a key role in supporting individuals with co-occurring medical and behavioral health needs through a person-centered, whole-health approach. This position combines hands-on clinical care with collaborative care coordination—ensuring our patients have the support they need to achieve better health outcomes. This is a great opportunity for someone who thrives in a fast-paced, team-oriented primary care setting and is passionate about making a meaningful impact on health equity and chronic disease management in underserved communities. Key Responsibilities Manage a caseload of up to 250 Health Care Home patients Complete annual care plans and ongoing monitoring of patients’ medical needs Develop and support health-related treatment plan goals for patients with chronic conditions Provide client education on health conditions, medications, prevention, and self-care Collaborate with primary care providers, care teams, and specialists to coordinate comprehensive care Monitor patient records, reports, and alerts (e.g., hospital admissions, medication needs) using HIT tools and EMRs Perform medication reconciliations after hospital discharges and assist with follow-up care Analyze data and trends (e.g., DRVS reports) and contribute to performance improvement efforts Support documentation and tracking of Uniform Data System (UDS) quality measures Serve as a clinical resource for patients, staff, and care team members Participate in multi-disciplinary team meetings and contribute to holistic care planning Seek and provide culturally responsive services to meet individual and family needs Report to the Regional Primary Care Nursing Director for clinical supervision and support Requirements, Skills, Knowledge and Expertise High School/GED required Practical Nursing or Associate of Nursing degree required Bachelor’s degree in nursing preferred Work Experience/Training/Additional Requirements: Proficiency in Microsoft Office Suite and Electronic Medical Records preferred Licensure/Certification: Licensed Practical Nurse (LPN) or Registered Nurse (RN) required You’ll Be A Great Fit for This Role if You: Are passionate about person-centered care and chronic disease management Feel confident navigating both primary care and behavioral health systems Excel in team-based settings and value collaboration with other providers Stay organized and detail-oriented in fast-paced clinical environments Are proactive in using data and health IT tools to drive patient outcomes Believe that integrated care is essential for promoting long-term wellness *Retention bonuses paid as per bonus policy; exclusions may apply. IND2