RN Case Manager

RN Case Manager Connect Health + Wellness is seeking candidates for an RN Case Manager, for Full Time employment. Connect Health + Wellness is committed to providing primary health, dental and integrated behavioral health services at our Federally Qualified Health Center sites and our Dental clinics by promoting health, reducing health risk factors and increasing access to medical and dental services, primarily for the uninsured and underserved in our Service Area. Additionally, we offer chronic disease self-management, medication assistance, and care coordination services to patients and residents within our service area.

Purpose:

Every position with Connect Health + Wellness exists to help the organization realize its Mission of providing medical, dental, and other health related services to uninsured and underinsured members of our community. As a valued member of our staff, it is critically important that this goal be the motivation for all your activities in the performance of your duties and responsibilities.

Position Summary:

The RN Case Manager plays a critical role in coordinating, managing, and delivering high quality care for patients across multiple clinic sites. This position focuses on preventive care, chronic disease management, and transitional care services while ensuring patients receive comprehensive, individualized care. The RN Case Manager will perform annual wellness visits, chronic care management, and care coordination activities, including care plan development and follow-up. Travel between clinics and sites is a regular expectation of this role. Key Responsibilities of the position Annual Wellness Visits (AWVs) Conduct AWVs in accordance with Medicare guidelines. Assess patient health status, review medications, and identify preventive care needs. Document and communicate findings to the care team. Chronic Care and Case Management Provide structured care management for patients with chronic conditions. Monitor patient progress and adherence to care plans. Educate patients and families on disease management, lifestyle modifications and self-care strategies. Coordinate care across multiple providers and clinic sites. Identify high-risk patients and develop individualized care plans. Care Plan Development and Maintenance Develop, implement, and update comprehensive care plans tailored to each patient's needs and in accordance with PCMH (Patient Centered Medical Home) guidelines. Ensure documentation meets regulatory, payer, and organizational standards. Transition Care Management (TCM) Conduct post-discharge follow-ups with patients to ensure continuity of care. Coordinate with hospital and specialty providers to prevent readmissions. Patient Education and Advocacy Provide counseling and education to patients and families regarding health conditions and treatments. Advocate patient needs within the healthcare team and the broader community.

Performance Competencies Mission-Driven:

Demonstrates commitment to organizational mission.

Professionalism:

Maintains high standards of accuracy and thoroughness.

Initiative:

Shows enthusiasm and a proactive approach to responsibilities.

Teamwork:

Collaborates effectively and communicates openly with others.

Judgment:

Exercise sound decision-making aligned with organizational values.

Dependability:

Reliable and punctual with a strong work ethic.

Organization:

Effectively manages time, priorities, and resources. Benefits for Full-time Employment Paid Holidays (8) Paid Time Off (160 hours) Simple IRA Plan (with company match) Medical, Dental and Vision Insurance Life Insurance provided by employer Short-term and Long-term Disability coverage provided by employer Other voluntary plans available No nights or weekend work Opportunity for student loan repayment