What are the responsibilities and job description for the Registered Nurse Care Manager position at Southern NH Internal Medicine?
Job Overview
We are a patient-centered private primary care practice dedicated to delivering high-quality, personalized care. We are seeking an experienced and compassionate RN Care Manager / Transitions of Care Specialist to help coordinate care across healthcare settings, improve patient outcomes, reduce avoidable hospital readmissions, and enhance the patient experience.
The RN Care Manager serves as a key member of our clinical team, focusing on care coordination and transitional care management for patients discharged from hospitals, skilled nursing facilities, emergency departments, and other care settings. This role works closely with providers, patients, families, specialists, community resources, and insurance plans to ensure seamless, patient-centered transitions and ongoing care management.
Duties
- Conduct Transitional Care Management (TCM) outreach within required regulatory timeframes.
- Review hospital, emergency department, and skilled nursing facility discharge summaries and reports.
- Perform comprehensive post-discharge assessments and medication reconciliation.
- Identify and address barriers to care, including social determinants of health.
- Work with our Care Management team to coordinate follow-up appointments with providers and specialists.
- Develop individualized care plans for high-risk and chronic disease patients.
- Educate patients and caregivers on diagnoses, medications, treatment plans, and self-management strategies.
- Collaborate with physicians, advanced practice providers, specialists, home health agencies, and community resources.
- Monitor patient progress and intervene proactively to prevent complications and readmissions.
- Document all care management activities accurately within the electronic medical record (EMR).
- Support quality initiatives, population health programs, and value-based care objectives.
Experience
Required:
- Active Registered Nurse (RN) license in good standing.
- Minimum 3 years of clinical nursing experience.
- Strong knowledge of care coordination, transitional care management, and chronic disease management.
- Excellent communication, patient education, and organizational skills.
- Proficiency with electronic medical records (EMR/EHR) systems.
- Ability to work independently while collaborating effectively with a multidisciplinary team.
Preferred:
- Experience in primary care, case management, population health, or value-based care.
- Experience with Medicare Transitional Care Management and Chronic Care Management programs.
- Familiarity with quality metrics such as HEDIS, MIPS, and Medicare quality programs.
Join us to lead innovative patient-centered care while advancing your career in a vibrant healthcare environment dedicated to excellence!
Work Location: In person