Care Manager RN

Title: Care Manager RN

Division: Senior Services - VBC

Status: Exempt

Reports to: Director of Primary Care Integration

Revision date: March 2025

Supervises: NA

Purpose

According to prescribed policies and procedures of the organization, including all applicable federal, state and local regulations, and under the general supervision of the Director, the Care Manager RN is responsible for coordinating and optimizing patient care within a value-based healthcare model focused on proactive, patient-centered care to improve outcomes, reduce hospitalizations, and enhance cost-effectiveness. The position involves both remote and in-person patient interactions, collaborating with providers, payers, and care teams to ensure efficient and high-quality care delivery.

Essential Functions

Care Coordination & Case Management

• Conducts comprehensive patient assessments via telephonic and in-person visits.
• Develops and implements personalized care plans focusing on prevention, chronic disease management, and care transitions.
• Coordinates services across multiple healthcare providers, specialists, and community resources.
• Facilitates hospital discharge planning and post-acute care transitions to prevent readmissions.

Value-Based Care Implementation

• Ensures patients are evaluated and receive care aligned with value-based reimbursement models, focusing on quality outcomes rather than volume.
• Collaborates with providers to reduce unnecessary hospitalizations and emergency room visits.
• Implements evidence-based interventions to enhance patient engagement, adherence, and overall well-being.

Patient Advocacy & Education

• Educates patients and caregivers on disease management, medication adherence, lifestyle changes, and preventive care.
• Provides telephonic and in-person support for high-risk or complex patients.
• Identifies and addresses social determinants of health (SDOH) that impact patient outcomes.

Data-Driven Decision Making & Reporting

• Utilizes electronic health records (EHR) and population health management tools to track patient progress.
• Reviews and analyzes patient data to identify care opportunities and recommend opportunity intervention.
• Ensures documentation complies with regulatory and quality standards for value-based care programs (e.g., Medicare Advantage, ACOs, Medicaid Managed Care).

Expectations

• Demonstrates and maintains a positive, professional manner, manages time efficiently and effectively, provides leadership as a role model to promote a team approach, collaborates and participates in policy creation and appropriate problem-solving methods.

• Must adhere to all policies, procedures, terms and conditions set forth in the National Church Residences' Employee Information Guide (EIG), the Code of Conduct, as well as any facility handbook, including but not limited to, corporate compliance, drug free workplace, safe work practices, all federal, state, local regulations and laws

• With respect to Resident Rights, ensures all care is provided with respect and dignity for the residents/clients, their families and the staff. Reports all complaints made by residents/clients and/or families to the appropriate supervisors, reports all allegations of abuse, misappropriation of funds/resident property and/or any other corporate compliance, drug free workplace, safe work practices, all federal, state and local regulations and laws.

• Completes all annual education requirements timely, including but not limited to Compliance, Privacy, Security and HIPAA training and exhibits behavior as set forth by the Code of Conduct in the performance of their duties

• Performs other duties as assigned.

Job Specification Sheet- Care Manager RN

Education: Degree in nursing field as a registered nurse from an approved school of nursing.

Experience: Minimum of two years as an RN in a clinical setting required. Prefer case management and/or experience working in assisted living or nursing facility.

Skills: Must have strong working computer skills with basic professional computer software (Microsoft Office suite, Windows, etc.) and the capacity for learning new software systems quickly. Must be self-directed with excellent organizational skills and the ability to manage tasks and assignments concurrently. Must have strong motivational skills and a high emotional intelligence quotient (EQ).

Mental: Must have good verbal and written communication, comprehension, computer and interpersonal skills. Must have the ability to speak, read, write and understand English.

Travel: Some, up to 25%. Must have a valid driver's license, automobile insurance and qualified to driver under the organization's motor vehicle check.

Licensure: Must hold an active Registered Nurse (RN) license in the state of practice.

Vision: Normal: Consistent with standard workflow.

With respect to said job description, estimate the daily time spent performing the following activities.

Rare (R) = 0-24%; Sometimes (S) = 25-49%; Frequent (F) = 50-74%; Continuous (C) = 75% plus

R = Climbing S = Stooping Lifting/Carrying: S = 10 - 25 lbs

S = Standing S = Pushing S = 26 - 50 lbs

F = Sitting S = Pulling R = 50 - 75 lbs

S = Walking S = Driving R = 76 plus lbs

Consequences of Errors: Significant monetary responsibility.

Supervision Received: General supervision: Employee generally operates by himself/herself checking with supervisor when in doubt.

Working Conditions: Due to visiting clients in home/facilities, exposure to some disagreeable conditions such as noise, odors, illness, infection and physical contact with disruptive clients.

Acknowledgement

I hereby understand and agree to the above description of the duties required.

Signature Date

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, ancestry, military status, disability, genetic information and/or any other characteristics protected by applicable law.