Chronic Care Manager / Outpatient Clinic Registered Nurse

Chronic Care Manager / Outpatient Clinic Registered Nurse

Full Time, Valhalla, NY

About the Role

The Chronic Care Manager /  RN provides direct clinical nursing support, care coordination, chronic care management, and operational support for WIHD Medical Outpatient Services. Working closely with the Registered Nurse Manager, providers, medical assistants, and administrative staff, this position helps ensure efficient clinic operations, exceptional patient experiences, high-quality clinical outcomes, and continuity of care.

Approximately 50% of this role is dedicated to Chronic Care Management (CCM), including patient outreach, care planning, education, monitoring, and coordination of services for individuals with complex healthcare needs.

This is an excellent opportunity for a compassionate and organized Registered Nurse who enjoys building relationships with patients while playing a key role in improving long-term health outcomes.

Essential Responsibilities

Clinical Triage, Assessment & Direct Patient Care

• Perform nursing triage for patient telephone calls, portal messages, walk-ins, and urgent clinical concerns.
• Assess patient acuity and prioritize care needs, escalating concerns to providers as appropriate.
• Administer medications, immunizations, treatments, and nursing interventions within RN scope of practice.
• Collaborate with group home agencies and caregivers to address concerns and share relevant clinical information.
• Accurately document all patient interactions within the electronic health record (EHR).

Care Coordination & Chronic Care Management (Approximately 50% of Role)

• Manage complex patient care issues and coordinate services among all members of the care team.
• Develop, implement, and update individualized care plans in collaboration with providers, patients, caregivers, and community partners.
• Conduct outreach and follow-up calls to monitor patient status, treatment adherence, and care plan goals.
• Support transitions of care following hospitalizations, emergency department visits, and specialty consultations.
• Coordinate services with providers, pharmacies, hospitals, community agencies, and payers.
• Promote preventive care, wellness initiatives, self-management, and patient education.
• Monitor changes in patient condition and ensure care plans are followed and updated as needed.
• Maintain timely and accurate documentation of all care coordination activities.
• Escalate clinical concerns to supervising providers and leadership when appropriate.

Referrals, Authorizations & Follow-Up

• Obtain prior authorizations for medications, diagnostic testing, procedures, and specialty services.
• Coordinate referrals to internal and external providers.
• Track referrals, consultations, and diagnostic testing through completion.
• Follow up on outstanding laboratory and diagnostic results and communicate findings as directed by providers.

Medication Management

• Process prescription refill requests in accordance with established protocols.
• Perform medication reconciliation and review for accuracy, adherence concerns, and potential interactions.
• Collaborate with pharmacies to resolve prescription, dosing, refill, and medication-related questions.

Clinic Operations & Quality Support

• Partner with the Nurse Manager to support efficient clinic workflow and patient flow.
• Assist with chart preparation, quality reporting, care gap closure, and population health initiatives.
• Help maintain compliance with infection control, patient safety, regulatory requirements, and quality improvement standards.
• Respond to medical emergencies and support emergency preparedness activities.

Staff Education & Team Support

• Provide mentorship, training, and clinical support to Medical Assistants and other clinic support staff.
• Assist with onboarding and competency development for new employees.
• Serve as a clinical resource regarding chronic disease management, medications, patient education, and clinical workflows.

Qualifications

Minimum Qualifications:

• Current Registered Nurse (RN) license in New York State.
• Current American Heart Association (AHA) Basic Life Support (BLS) certification.
• Minimum of two years of clinical nursing experience.
• Experience in ambulatory care, primary care, care coordination, or care management preferred.
• Strong assessment, triage, communication, organizational, and care coordination skills.
• Proficiency with electronic health records (EHRs) and clinical documentation.

 Preferred Qualifications

• Experience with Chronic Care Management (CCM) programs.
• Experience working with individuals with intellectual and developmental disabilities (I/DD).
• Bilingual English/Spanish proficiency.

Physical Requirements

• Frequent standing, walking, speaking, grasping, and carrying.
• Regular sitting, reaching, bending, stooping, lifting, pushing, and pulling.
• Ability to lift and move up to 50 pounds with assistance when necessary.
• Frequent use of computers, telephones, printers, copiers, and other office equipment.
• Frequent exposure to bodily fluids and other conditions common to healthcare environments.
• Potential exposure to infectious diseases, biological materials, medications, toxic substances, and ionizing radiation.

Benefits

• Medical and Dental Insurance
• FSA or HSA
• Paid Time Off (Vacation, Sick, Personal and Holidays)
• Term Life insurance 
• Short and Long-Term Disability 
• 403B employer contribution 

About WIHD?

At WIHD, you'll be part of a collaborative healthcare team dedicated to improving access, quality, and continuity of care for individuals and families throughout our community. We value compassionate care, professional growth, innovation, and teamwork, and we are committed to helping our staff thrive while making a meaningful difference in the lives of our patients.

 Equal Opportunity Employer

WIHD is committed to fostering a workplace culture that values respect, fairness, and equal opportunity. Employment decisions are based on individual qualifications, experience, and business needs. We comply with all applicable laws and do not discriminate on the basis of race, color, national origin, citizenship status, religion, age, sex, marital status, sexual orientation, gender identity, disability, veteran status, pregnancy, or any other status protected by law.