RN CARE MANAGER

POSITION SUMMARY:

The RN Care Manager provides intensive, relationship-based care coordination for medically and socially complex patients at high risk for emergency department utilization, hospitalization, poor health outcomes, and fragmented care. This role focuses on helping high-risk patients navigate the healthcare system, improve engagement in primary care, reduce avoidable utilization, and address barriers impacting health and wellness.

The RN Care Manager functions as a central point of coordination for an active panel of high-need patients and emphasizes proactive outreach, transitional care management, chronic disease support, depression and mental health screening, patient advocacy, and coordination across care settings.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Patient Identification and Enrollment

• Identify patients who may benefit from high utilizer care management using established clinical, utilization, and social complexity criteria, with emphasis on sustained or escalating utilization patterns rather than single-episode spikes
• Utilize population health tools, registries, risk stratification reports, screening results, and utilization data to identify patients at risk for or living with chronic health conditions and prioritize proactive interventions
• Participate in interdisciplinary case review and patient prioritization, incorporating both data-driven identification and provider/team referral to capture patients whose complexity may not be reflected in quantitative data alone
• Maintain an active panel of high-risk patients appropriate to program capacity, adjusting based on acuity and intensity of patient needs.
• Reassess patient enrollment status at regular intervals using defined step-down and graduation criteria.

Care Coordination

• Develop individualized, patient-centered care plans in collaboration with patients and care teams, incorporating patient-defined goals and preferences.
• Coordinate care across primary care, behavioral health, specialty care, hospitals, emergency departments, pharmacies, and community organizations
• Provide structured transitional care management following emergency department visits and hospitalizations.
• Assist patients in overcoming barriers related to transportation, housing instability, medication access, insurance issues, food insecurity, and healthcare system navigation
• Facilitate warm handoffs between team members and services
• Coordinate with community providers to extend outreach, social support, coaching, advocacy, and navigation services to enrolled patients

Patient Engagement

• Build therapeutic, trauma-informed relationships with patients experiencing complex medical, behavioral health, and social challenges
• Conduct outreach via phone, text, telehealth, and in-person encounters
• Provide education regarding chronic disease management, medications, preventive care, and treatment plans
• Use motivational interviewing to promote engagement in services to prevent and manage of chronic health conditions, including behavioral health, lifestyle modification, disease self-management, and community-based support programs

Clinical Support

• Perform medication reconciliation following hospital discharge or transitions of care
• Administer and track standardized screening tools
• Monitor and support adherence to evidence-based care plans for chronic disease prevention and management, escalating concerns and care gaps to the appropriate clinical team members
• Assist with coordination of preventive care and follow-up appointments
• Support safe care transitions and continuity of care
• Provides coverage for other RN Care managers as needed.

Collaboration and Documentation

• Participate in interdisciplinary team meetings and case conferences
• Document patient interactions, care plans, screening results, and outcome measures accurately within the electronic health record
• Utilize registries, reports, and utilization data to guide patient management and track program outcomes
• Collaborate with leadership on quality improvement initiatives related to high-risk populations
• Contribute to program evaluation by tracking and reporting on key performance indicators.
• Attends monthly clinic meetings, Nursing Department meetings, and daily POD huddles.
• Assists with onboarding and training of clinical staff as indicated.

KNOWLEDGE, SKILLS AND ABILITIES

ANHC’s Mission, Vision and Values: Actively supports ANHC’s mission, vision and values.

Includes using individual skills to add value to the mission

• To be a trusted partner in every person’s wellness by providing integrated, compassionate, and high-quality health care, regardless of ability to pay; and vision: Accessible care for a healthy Anchorage.
• Aligns actions around organizational values of RESPECT, COMPASSION, PERSONAL INTEGRITY, EXCELLENCE and COLLABORATIVE SPIRIT and gives priority to organizational mission, vision and values when making decisions.

Accountability

Takes ownership for delivering on commitments; owns mistakes and uses them as opportunities for learning and development; openly discusses his/her actions and their consequences both good and bad; has an ability to identify strengths and developmental opportunities and leverages insight to make adjustments to improve their effectiveness; courage to have difficult conversations.

Adapting to Change

Accepts and adapts to change in a professionally appropriate and thoughtful manner. Is willing to offer a different perspective or approach and yet knows when and how to stand down graciously and accept a well-thought-out decision. Embraces change.

Confidentiality

Maintains the highest level of confidentiality regarding ANHC records and information relating to ANHC, its customers and employees. Appropriately uses internal confidential information for business purposes only. Responsible for knowledge and compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Communicating Effectively

Shares information. Listens and involves others. Clearly conveys ideas in a manner that engages others and helps them understand and retain the message.

Decision Making/Judgment

Approaches problems and decisions methodically and objectively; involves others as needed; uses sound judgment in making decisions and understanding the impact to themselves, customers, their team, and the organization; conducts the appropriate analysis to identify the symptoms and root cause of issues; makes timely decisions.

Delivering High Quality Work

Makes sure responsibilities central to the role meet all requirements and expectations. Finishes tasks promptly and critically reviews work to ensure quality and accuracy. Considers impact of work to others and takes steps to mitigate.

Seeks additional work after finishing tasks.

Demonstrating Initiative

Takes action on his/her own without being prompted; handles problems independently; able to resolve issues without relying on extensive help from others; does more than is expected or asked.

Results Orientation

Is focused on outcomes and accomplishments; follows through on commitments; can be counted upon to successfully execute on goals; motivated by achievement and a need for closure; has an attention to detail and is both efficient and effective in achieving a high level of measurable outcomes; persists in achieving goals despite obstacles.

Service Excellence

Has a desire to consistently provide a genuinely exceptional experience to every person, every time. Provides timely and professional service to both internal and external customers; is responsive to customer needs and requests; is always courteous to the customer and considers the needs of the customer when making decisions.

Teamwork

Meets all team deadlines and responsibilities, listens to others and values opinions, helps team and leader to meet goals, welcomes newcomers and promotes a team atmosphere.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.

Work Experience

• Four years of progressively responsible nursing experience in primary care, ambulatory care, community health, or population health setting.
• Experience working within a Patient-Centered Medical Home (PCMH) model preferred.

Education, Certification and Licensure

Active license as a Registered Nurse in the State of Alaska. Must have and maintain current BLS certification.

Additional Skills & Knowledge

• Bilingual skills preferred.
• Maintains current knowledge of evidence-based practices, clinical guidelines, population health strategies, and care management principles relevant to the patient populations served.
• Participates in ongoing professional development activities, continuing education, training, and competency development to support high-quality patient care and program effectiveness.

PHYSICAL, SENSORY, ENVIRONMENTAL QUALIFICATIONS

• The work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
• While performing the duties of this job, the employee is frequently required to sit and occasionally required to walk and stand.
• The employee may occasionally be required to lift and/or move up to 20 pounds.
• Work is performed in a healthcare clinic and office setting.
• ANHC is a tobacco-free campus.

EQUAL EMPLOYMENT OPPORTUNITY

STATEMENT:

Anchorage Neighborhood Health Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws.

Anchorage Neighborhood Health Center complies with applicable state and local laws governing non-discrimination in employment in every location in which the organization has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Persons alleging unequal treatment should contact the Chief Human Resources Officer.

The undersigned have read this job description and agree that it defines the position as it currently exists. The undersigned also understands that the above is intended to describe the general content of and requirements for this job. It is not to be considered as an exhaustive statement of duties, responsibilities, or requirements and does not limit the assignment of additional duties at the discretion of the supervisor.