The Registered Nurse Case Manager (Primary Care) is responsible for coordinating comprehensive patient care services, ensuring continuity of care, improving clinical outcomes, and supporting primary care providers. This role focuses on assessment, planning, implementation, and evaluation of patient-centered care.
Conduct clinical assessments to identify patient needs and develop individualized care plans.
Coordinate care across multidisciplinary teams, including physicians, nurses, therapists, and social workers.
Monitor patient progress and modify care plans as needed.
Provide education to patients and families on chronic disease management, medications, and health promotion.
Ensure smooth transitions of care between hospital, clinic, and home settings.
Track patient outcomes, maintain detailed documentation, and ensure adherence to care protocols.
Support preventive care measures, follow-up appointments, and outreach programs.
Serve as a patient advocate, ensuring access to necessary resources and services.
Utilize EMR systems to update, review, and track patient information.
Collaborate with primary care providers to improve quality metrics and patient satisfaction.
Active & unencumbered Registered Nurse (RN) license.
Bachelor of Science in Nursing (BSN) preferred.
Minimum 2–3 years of clinical nursing experience (Primary Care, Case Management, or Chronic Care preferred).
Strong knowledge of care coordination, population health, and chronic disease management.
Excellent communication, critical thinking, and organizational skills.
Experience with EMR/EHR systems.
Case Management Certification (CCM) or equivalent.
Experience in primary care, family medicine, or outpatient settings.
Strong understanding of community health resources.
Ability to work independently and manage multiple priorities.