RN Care Manager

Caring for our community starts with you. Join a team that believes everyone deserves care.

Candidates must reside within NorthLakes' service area at the time of hire and maintain residency throughout employment.

The RN Care Manager will manage high risk and chronic illness to promote whole-person, integrated, quality care. The RN Care Manager will employ a person-centered and team approach, partnering with patients and their family/caregiver(s), clinic/hospital/providers and specialty providers and other staff, and community resources. 

• Conduct in-office patient visits as outlined in care plan and based on patient’s health status and self-management interests 

• Create and promote engagement with a care plan, developed with the patient, primary care provider and/or specialty care provider and family/caregiver(s) 

• Support the delivery of integrated, whole-person care in family medicine, recovery and psychiatric care. 

• Engage patients in self-management and shared decision-making 

• Increase utilization of preventative care services 

• Promote timely access to appropriate care to reduce emergency room utilization and hospital readmissions 

• Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals  

• Work with internal providers on coordinating schedules, getting a client in to other service lines as needed 

• Facilitate patient access to appropriate medical and specialty providers, assisting with residential and detox referrals 

• Assist with the identification of “high-risk” patients with a chronic illness and those with special health care needs, coordinate care, and track outcomes 

• Assess for social drivers of health and work with Community Health Workers on integrated Care Management 

• Attend all Care Management training courses/webinars and meetings – contribute to the development of the Care Management Program 

• Participate in quality improvement efforts by; utilizing dashboards, tracking tools and providing quality reporting data monthly  

• Follow protocols, clinical policy and procedure in collaboration with the Primary Care Provider/Specialty Care provider for chronic care management. Follows clinical guidelines protocols and policies related to all direct patient care.  

• Performs in-clinic triage and medication refills  

• Work with Triage Nurse team as needed to perform medication refills and triage. 

• Conducts nursing assessments according to assessment tools to determine services and service level of care needed. 

• Under provider direction performs and/or assists provider in inductions utilizing COWS, administers patient injections and provides education on naloxone. 

• Helps monitor OB clients, talking with their OB provider about pain management for delivery and postpartum. 

• Provides education about Neonatal Abstinence syndrome, support systems, and concerns 

• General Education with patients about substance use, tobacco cessation, prevention, communicable disease management, new medical diagnosis 

• Monitor medication adherence, including checking the PDMP, help monitor side effects, provide patient education, assist prior authorizations and prescription assistance programs 

• Provide medication reconciliation and complete refill requests, including for controlled substances under direction and approval from prescribing provider 

• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care cost    

• Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources  

• Facilitate and attend meetings between patient, family/caregiver(s), care team, and community resources, as needed