RN Care Manager Advanced Primary Care

A Brief Overview

Under general supervision of the Supervisor, APC Care Management, the APC Administrator and the Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), perform as a member of the healthcare team to apply the nursing process when making nursing judgments and decisions specific to assessment, planning, implementation/delivery, and evaluation of patient care, and documenting relevant data and care processes. The RN Care Manager will facilitate communication between the patients and their Primary Care Providers. In addition, the RN Care Manager will assist with chronic disease action plans, transitional care management, Advance Directives planning, Annual Wellness Visits, and preventative care utilizing assessment skills both in person and telephonically. This RN position will be a resource for other team members and critical thinking skills are a must

What You Will Do

• Exercise professional nursing judgment appropriate to the level of care needed, and prioritizing patient acuity and workload demands. The RN Care Manager will function with greater autonomy by consistently demonstrating independent clinical decision making abilities.
• Provide patient care in a manner that demonstrates nursing knowledge and technical competence; recognize significant changes in patient’s condition/situation and take appropriate action. Communicate with patient/family including but not limited to relaying physician orders and changes in the plan of care, etc.
• Assist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with appropriate rules/regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family.
• Work as a leader in the Advanced Care Model in the ambulatory practice as assigned and work collaboratively with the APC Administrator and Director of APP & UHPS Nursing to drive system wide initiatives and changes
• RN care management integrated into Primary Care office responsible for managing patient’s care across the continuum
• Analyze sources of data to identify high risk patients and member groups
• Manage high risk patients including patients with multiple comorbidities or high risk for readmission
• Develop longitudinal care planning that includes assessment, planning, implementation and monitoring
• Coordinate continuity of care with patients and families following hospital admission, discharge and ER visits
• Advocate for patients by assisting in navigation of the health system
• Communicate to the care team the patient’s goals and progress
• Participate in quality improvement initiatives
• Participate on data collection team to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement
• Provide 1 on 1 office visits for patients to implement care planning
• Provide health and disease education to patients and families, including group education opportunities
• Support patients in self-management of their disease and behavior modification interventions
• As a member of the community care team, identifies appropriate resources including specialists, facilities, and external healthcare organization supports to provide an interdisciplinary approach
• Collaborate with office staff in the coordination of individual patient care needs
• Support and facilitate advanced care planning for patients and their families
• Demonstrate proficiency and act as an expert role model in the performance of patient care

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

%3Cb%3EEducation%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E Graduate of an accredited school of nursing (Required) and %3C/li%3E%3Cli%3EBachelor%27s Degree (Preferred) %3C/li%3E%3C/ul%3E%3Cb%3EWork Experience%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E3+ years Clinical experience (Required) and %3C/li%3E%3Cli%3E1+ years In the outpatient, ED or urgent care setting (Preferred) and %3C/li%3E%3Cli%3E Experience working with Electronic Medical Record application and other computer based patient management tools (Required) %3C/li%3E%3C/ul%3E%3Cb%3EKnowledge, Skills, %26amp; Abilities%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E Knowledge in navigation of the health care system, including benefits coverage and health treatment protocols (Preferred proficiency) %3C/li%3E%3Cli%3E Excellent verbal and written communication skills (Required proficiency) %3C/li%3E%3Cli%3E Proven skills in negotiation and collaboration (Required proficiency) %3C/li%3E%3Cli%3E Proven time management and organizational skills (Required proficiency) %3C/li%3E%3Cli%3E Demonstrated excellence in customer service (Required proficiency) %3C/li%3E%3Cli%3E Demonstrated ability to apply concepts, utilize sound judgment and work independently. (Required proficiency) %3C/li%3E%3Cli%3E Good computer skills and ability to utilize Microsoft Outlook, Excel, Word, and Power Point. (Required proficiency) %3C/li%3E%3C/ul%3E%3Cb%3ELicenses and Certifications%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3ERegistered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) %3C/li%3E%3Cli%3E CCM or ACM (Preferred) %3C/li%3E%3C/ul%3E%3Cb%3EPhysical Demands%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3EStanding Frequently %3C/li%3E%3Cli%3EWalking Frequently %3C/li%3E%3Cli%3ESitting Rarely %3C/li%3E%3Cli%3ELifting Frequently up to 50 lbs %3C/li%3E%3Cli%3ECarrying Frequently up to 50 lbs %3C/li%3E%3Cli%3EPushing Frequently up to 50 lbs %3C/li%3E%3Cli%3EPulling Frequently up to 50 lbs %3C/li%3E%3Cli%3EClimbing Occasionally up to 50 lbs %3C/li%3E%3Cli%3EBalancing Occasionally %3C/li%3E%3Cli%3EStooping Frequently %3C/li%3E%3Cli%3EKneeling Frequently %3C/li%3E%3Cli%3ECrouching Frequently %3C/li%3E%3Cli%3ECrawling Occasionally %3C/li%3E%3Cli%3EReaching Frequently %3C/li%3E%3Cli%3EHandling Frequently %3C/li%3E%3Cli%3EGrasping Frequently %3C/li%3E%3Cli%3EFeeling Constantly %3C/li%3E%3Cli%3ETalking Constantly %3C/li%3E%3Cli%3EHearing Constantly %3C/li%3E%3Cli%3ERepetitive Motions Constantly %3C/li%3E%3Cli%3EEye/Hand/Foot Coordination Constantly %3C/li%3E%3C/ul%3E%3Cb%3ETravel Requirements%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E10% %3C/li%3E%3C/ul%3E

Job Details
Primary Location: United States-Ohio-Streetsboro
Other Locations: United States-Ohio-Hudson
Work Locations: 9318 St Rt 14, Streetsboro, 44241
Job: Nurse – more than 1 year experience
Organization: Primary_Care_UHMSO
Schedule: Full-time
Employee Status: Regular
Shift: Days
Job Type: Standard
Job Level: Professional
Travel: Yes, 10 % of the Time
Remote Work: No
Job Posting: Sep 1, 2026, 3:20:04 PM