LPN/RN Nurse Care Manager - PCHH

Job Description

Job DescriptionDescriptionTo support the continued delivery of quality and compassionate care in our communities, we are offering a retention bonus of $4,000.* 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

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 ExpertiseHigh 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