Clinical Care Management Nurse

•Primary Care/ Family Medicine Avenue Health Okemos, MI Job Details Full-time $28

•$38 an hour 3 hours ago Benefits Wellness program Health insurance Paid time off Vision insurance Life insurance Paid sick time Qualifications Nursing Teamwork RN License Internal medicine Phone triage Full Job Description Clinical Care Management RN Primary Care /

Family Medicine Pay:

$28.00

•38.00 per hour, based on experience and qualifications. Position Summary We are seeking an organized, compassionate, and proactive Registered Nurse to support our family medicine team through care management, population health, quality improvement, chronic disease management, and clinical telephone triage. This role is ideal for an RN who enjoys developing long-term relationships with patients, coordinating care, closing gaps in care, and helping improve both individual patient outcomes and practice-wide quality performance. Key Responsibilities Manage patients enrolled in PDCM, Chronic Care Management (CCM), and other care-management programs . Complete patient assessments, individualized care plans, education, follow-up, and chronic disease support. Coordinate care with providers, specialists, hospitals, pharmacies, home health agencies, and community resources. Review patient panels and payer reports to identify and close preventive and chronic-care gaps. Support quality measures related to diabetes, hypertension, statin therapy, medication adherence, cancer screening, immunizations, annual wellness visits, kidney health, and other payer/HEDIS measures. Perform proactive patient outreach and obtain missing outside records, testing, and specialist documentation. Provide clinical telephone triage using established protocols and nursing judgment. Determine appropriate patient disposition, including office evaluation, urgent care, emergency care, home management, or provider review. Provide patient education regarding medications, chronic conditions, testing, and treatment plans. Review medication refill requests and assist with medication reconciliation. Follow appropriate patients after emergency department visits and hospitalizations. Assist with transitional care, high-risk patient follow-up, and coordination of timely appointments. Maintain accurate and timely documentation in the electronic medical record. Participate in quality-improvement and population-health initiatives. Serve as a clinical resource for other members of the care team. Qualifications Current Michigan Registered Nurse (RN) license in good standing. Primary care, family medicine, internal medicine, care management, population health, case management, or telephone triage experience preferred. Chronic disease management experience preferred. Familiarity with PDCM, CCM, HEDIS, PCMH, or value-based care is highly desirable. Strong clinical assessment, communication, and organizational skills. Ability to work independently while collaborating closely with providers and staff. Comfortable using electronic medical records and managing multiple patient follow-up needs. Athenahealth experience is a plus. Ideal Candidate You are proactive rather than reactive, comfortable taking ownership of patient follow-up, and enjoy identifying needs and seeing them through to completion. You value teamwork, clear communication, excellent patient care, and continuous improvement within a primary care setting.

Pay:

$28.00

•$38.00 per hour Expected hours: 40.0 per week

Benefits:

Health insurance Life insurance Paid sick time Paid time off Vision insurance Wellness program

Work Location:

In person