RN Care Manager: Chronic Care Coordination Leader

Jobtailor; Four Oaks (NC); On-site; USD 65,000 - 90,000; Full time

Job summary

Jobtailor is seeking a Registered Nurse to join our care management team in North Carolina. The role focuses on identifying patients for care management, assigning acuity levels, and guiding care team assignments to develop individualized plans.

Responsibilities include coordinating with PCPs and the care team, managing transitions of care, medication reconciliation, education, and collaboration with community partners to improve outcomes for patients with multiple chronic conditions.

Qualifications

• Graduate of an accredited RN program.
• North Carolina RN license is required.
• 2+ years of experience in primary healthcare, ambulatory care and/or home health within the last 5 years.
• High school diploma or GED.
• Comfortable navigating an electronic health record (EHR).
• Valid North Carolina driver's license and clean driving record, approved for driving privileges.
• Experience with underserved or rural populations preferred.
• Spanish speaking preferred, not required.

Responsibilities

• Identify patients who meet criteria for the care management program.
• Review charts to assign acuity levels and assign patients to the appropriate care team.
• Provide oversight to Care Coordinators completing comprehensive assessments and developing individualized care plans.
• Develop and update care plans in collaboration with patients, PCPs, and the care team.
• Support transitions of care, including medication reconciliation, follow-up, specialist referrals, barriers to care, and education.
• Coordinate communication with community partners such as hospitals, emergency departments, and discharge planners.
• Support PCMH implementation and help teams understand care coordination workflows.
• Monitor outcomes, identify gaps, and recommend improvements.
• Coordinate care for patients with multiple chronic conditions as part of a multidisciplinary population-management team

Skills

Care coordination

EHR navigation

Patient care management

Spanish speaking

Chronic condition management

Care plan development

Education

RN licensure (North Carolina)

High school diploma or GED

Tools

EHR systems

Job description

Jobtailor is seeking a Registered Nurse to join our care management team in North Carolina. The role focuses on identifying patients for care management, assigning acuity levels, and guiding care team assignments to develop individualized plans.

Responsibilities include coordinating with PCPs and the care team, managing transitions of care, medication reconciliation, education, and collaboration with community partners to improve outcomes for patients with multiple chronic conditions.