RN Care Manager

THE LAKES COMMUNITY HEALTH CENTER INC; United States; On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical & dental insurance

Life & disability insurance

Health Savings Account

Flexible Spending Accounts

PTO & Holidays

Job summary

NorthLakes Community Clinic is seeking a Registered Nurse Care Manager to travel weekly between Ashland, Iron River, and Hurley locations. The role focuses on managing high‑risk and chronic illnesses, coordinating care, and engaging patients and families in self‑management plans.

The ideal candidate holds an Associates Degree in Nursing, WI RN license with CPR, and experience with EHR systems (Epic preferred). A patient‑centered, collaborative approach is essential.

Qualifications

• Associates Degree in Nursing is required.
• RN with two+ years related experience and/or training.
• Current, valid WI RN license and CPR certification are required.
• Experience with Electronic Health Records, preferably Epic.

Responsibilities

• Travel between Ashland, Iron River, and Hurley clinics on a weekly basis.
• Manage high risk and chronic illness to promote whole‑person, integrated care.
• Create and promote a patient care plan with the patient and care team.
• Coordinate schedules and referrals across service lines.
• Assist with social determinants of health and community resources.

Skills

RN Care Manager

Two+ years experience

CPR certification

Epic EHR

Care coordination

Patient education

Strong communication

Education

Associates Degree in Nursing

Tools

Epic EHR

Job description

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. To engage teams and patients in the delivery of evidence‑based, patient‑centered, lifelong care. Essential Job Functions Travel Requirement: This RN Care Manager position will travel between our Ashland, Iron River, and Hurley clinic locations on a weekly basis. 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.

Qualifications and Education Requirements

Minimum Level of Completed Education: Associates Degree in Nursing Prior years of experience in similar role: RN with two+ years related experience and/or training Experience with systems, computer applications/software: Electronic Health Records, preferably Epic.

Required (or Preferred) Licensure/Cert/Credentials: Current, valid and unrestricted WI license to practice as a Registered Nurse. Current CPR certification required. Evidence of leadership, communication, education and counseling skills. Local knowledge about community health care and social welfare resources preferred.

Benefit Statement For full time and part time employees who work 24 or more hours per week we offer a generous benefits package that includes:

• Medical and dental insurance
• Employer paid group term life and disability
• Employer contribution toward Health Savings Account
• Flexible Spending Accounts
• Paid Time Off (PTO), Paid Holidays and Paid Leave Bank
• 403(b) with a 4% employer match

Various voluntary benefits:

• Vision Insurance
• Supplemental Life, AD&D and Disability
• Tuition reimbursement
• Health and Wellness reimbursement program
• Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members
• Partner of HRSA/NHSC loan repayment program

Our Mission is to respond to the healthcare needs of our communities with an integrated array of quality services and actively remove barriers to wellness.

NorthLakes Community Clinic is an Equal Opportunity Employer. All qualified applicants will be considered for employment regardless of age, race, color, creed, religion, sex, sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.

All offers of employment are contingent upon successful completion of a criminal background check and references.

At NorthLakes Community Clinic, our organizational competencies highlight the behaviors and values that guide how we work and provide a shared foundation for performance, development, and growth throughout an employee’s career with us.

NorthLakes Community Clinic Organizational Competencies

• Mission Driven – Advances the organizational mission, vision and values in executing job duties.
• Customer Service – Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.
• Quality – Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.
• Creativity – Generates new ideas, supports change, provides innovative solutions, solves problems creatively.
• Integrity – Earns the trust and confidence of coworkers and customers through honest communication, ethical behavior and professionalism in all interactions.
• Teamwork – Contributes to meeting team deadlines and responsibilities, listens to others and values opinions, helps team to meet goals, welcomes newcomers and promotes a cooperative team atmosphere.
• Self‑Development – Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up‑to‑date, turns mistakes into learning opportunities.
• Job Knowledge – Understands duties and responsibilities, possesses necessary job knowledge and technical skills, maintains job knowledge current.
• Communication – Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.
• Dependability – Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.
• Trauma/Resilience Informed – Understands that trauma is prevalent and resilience can be cultivated and improved; and operates in a manner consistent with these principles.

NorthLakes Community Clinic is a Federally Qualified Community Health Center that operates 19 clinics in 19 communities throughout 13 counties in Wisconsin. We provide a variety of services based on the needs of the communities that we serve, including primary Medical, Dental, and Behavioral Health. All people are welcome to receive care regardless of their insurance status and ability to pay. For those that qualify we have a Sliding Fee Scale that is based on income. We are deeply involved in our communities providing Dental and Behavioral Health in schools, taking dental care to nursing homes, and working with WIC – Women, Infants, and Children. Since our opening in 2008, we aim to fill the gaps in healthcare and fulfill our vision of healthy, prosperous, engaged communities where everyone thrives. As a Community Health Center and National Health Service Corporation, we promise to serve all patients. Offer discounted fees for patients who qualify. Not deny services based on a person’s Race, Color, Sex, National Origin, Disability, Religion, Sexual Orientation, or inability to Pay. Accept insurance including Medicaid, Medicare, and Children’s Health Insurance Program. We are governed by a patient‑majority board that meets monthly.