Care Manager Registered Nurse

Hopscotch Primary Care; Lexington (NC); Hybride; USD 70 000 - 90 000; Plein temps

Résumé du poste

Hopscotch Primary Care in North Carolina seeks a Care Manager Registered Nurse (CMRN) for a hybrid role. You will manage high-acuity patient panels remotely with periodic in-clinic support, coordinating across providers and care teams to improve outcomes and care continuity.

The role emphasizes care coordination, patient education, and collaboration with interprofessional teams to deliver high-quality, patient-centered care in a value-based model.

Qualifications

• Licensed RN in North Carolina (active)
• BLS certification required
• Minimum 2 years of care management experience in a team-based setting
• Experience in primary care focused on chronic disease management preferred
• Experience with behavioral health and community organizations is a plus
• Strong verbal and written communication and customer service skills

Responsabilités

• Manage a defined panel of high-acuity patients, delivering longitudinal case management
• Develop and update individualized care plans with providers and care teams
• Perform telephonic outreach and monitoring to improve outcomes
• Coordinate care across providers, hospitals, and community resources
• Support in-clinic visits and home/community-based care as needed
• Engage patients and families, provide disease management education and coaching
• Adhere to care management protocols, documentation standards, and quality metrics

Connaissances

RN license NC

BLS

Care management

Primary care

Motivational interviewing

Communication

Description du poste

About Hopscotch Primary Care

At Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities. Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities. We are on a mission to transform healthcare in rural America. We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most.

Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch. Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time.

Today, we are serving thousands of patients in our value-based care model and the number is growing every day. If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we’d like to meet you.

ABOUT THE ROLE

TheCare Manager Registered Nurse (CMRN)is a hybrid roleresponsible for managing a panel ofhigher-acuitypatients (HPP)through a combination ofprimarily remote case management and targeted in-clinic support, such asHigh-RiskHuddle meetings .

This role is accountable forend-to-end care management, with a strong focus on:

• Reducingavoidable admissions (ADK)andemergency departmentutilization(EDK)
• Improving clinical outcomes and patient experience
• Supporting care continuity across the healthcare continuum

The CMRN partners closely withproviders, clinic staff, and Care Center Managers (CCMs)to deliver coordinated, proactive, and patient-centered care. This position is primarily remote, withregular in-office presencebased on patient or programneeds.

Specific responsibilities for this role will include, but are not limited to:

Panel Management & Care Coordination (Primarily– Remote)

• Manage a defined panelofhigh-risk patients, delivering comprehensive, longitudinal case management
• Develop, implement, and continuously update individualizedcare plansin collaboration with providers and care teams
• Perform ongoingtelephonicoutreachand monitoringto improve patient outcomes
• Coordinate care acrossthe patients HPC provider, specialists, hospitals, EDs, SNFs, and community resources
• Partner and collaborate withtransitions of careteam,for a smooth transition and to ensurethatthe patient needsare met following the transitions of care period

Clinical Collaboration & Outcomes Management

• Partner withproviders, MAs, LPNs, andCare Center Managersto align on patient care plans and priorities
• Escalate clinical concerns and barriers to care in real time
• Participate in team huddles, case reviews, and interdisciplinary care discussions
• Track and improvequality andutilizationmetricstied to patient outcomes

In-Clinic Responsibilities (Hybrid Component)

• Maintainin-office presenceminimum of 1 time a monthandas neededto:
  • Support high-risk patient visits
  • Assistwith care coordination for complex patients

Home & Community-Based Support

• Coordinate with in office LPN foroccasional home visitsfor high-risk or complex patients when clinicallyappropriate
• Assesssocial determinants of health, home safety, and barriers to care
• Coordinate community-based services and resources to supportpatientcare plangoals

Patient & Family Engagement

• Build trusted relationships with patients, families, and caregivers
• Provide education ondisease management, medications, and care plans
• Utilizemotivational interviewing and coaching techniquesto drive behavior change

Program Quality, Compliance & Best Practices

• Adhere to care management protocols, regulatory requirements, and documentation standards
• Support continuous improvement of care management workflows and outcomes
• Identifyand reportgaps, risks, or adverse events
• Contribute to development ofbest practices, training, and process improvements

ABOUT YOU

You would be a great fit for this position if you have a minimum of2years of experience as acare manager embedded into an interdisciplinary team and the following:

• Active registered nurse (RN) license in North Carolina
• BLS certification
• Experienceworking in a primary careclinicfocused on chronic disease management
• Experience withbehavioral health and community-based organizationspreferred
• Experience with motivational interviewing, behavior change, health promotion, and coaching
• Strong verbal and written communication skills and customer service orientation

At Hopscotch Primary Care, we embrace diversity, invest in a culture of inclusion and positivity and encourage all to apply to join our team. You will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.