Job Description

Job Title:                       Care Management Nurse

Reports To:                   Nursing Care Management Supervisor

Job Summary:                     Assists clinical staff and providers in the administration of patient care, population management, and care management in assigned clinical areas


Qualifications and Requirements:

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  This job description in no way implies that these are the only duties to be performed and may be modified, interpreted and/or applied in any way as necessary.  Maintaining regular and punctual attendance is required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.


Essential Job Duties:

  • Provides Clinical Nursing Support
  • Assists providers and assigned care team to meet population health goals by conducting health screenings, immunizations, and chronic disease management with focus on care managed patients.
  • Assists care team and provider with Medicare wellness visits for clinic population.
  • Completes pre-visit planning on care managed patients.
  • Completes provider orders for procedures that require advanced clinical and/or nursing skills.
  • Provides patient education as directed by provider.
  • Assists in developing educational materials for patients and staff.
  • Assists in providing clinical training and support to medical support staff.
  • Assists in conducting triage (with registered nurse license) or gathers information regarding urgent patient needs and communicates with provider to resolve patient care issues promptly.
  • With Registered Nurse license, takes critical test results such as labs and diagnostics and facilitates notifying provider and assuring prompt action is taken as directed by provider.


  • Care Management
  • Facilitates co-management of patients through transitions of care and referral with timely communication, inquiry, follow-up, and integration of information into the care plan. ?
  • Develops care plans in collaboration with patient, family/caregiver(s), providers, and other clinical staff.
  • Monitors patient adherence to care plans and evaluates effectiveness.
  • Identifies patient progress and facilitates changes to care plans as needed
  • Assesses patient unmet health care and social needs.
  • Assists in developing and implementing ongoing processes to determine and request the level of care coordination support that patients and caregiver(s) need and/or desire.
  • Facilitates patient access to appropriate medical and specialty providers and other care givers.
  • Educates patient and family/caregiver(s) about relevant community resources. ?
  • Facilitates and attends meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed.


  • Assists care team in the administration of patient care for care managed patients, and as back up for medical support staff.


Required Education, Experience, Certificates & Licenses:

  • Degree from an accredited nursing program.
  • Current Unrestricted Arizona State Nursing (RN or LPN) license.
  • Cardiopulmonary Resuscitation (CPR) certification required.
  • Experience in a clinical setting preferred.
  • Driver's License and Proof of Insurance may be required if requesting mileage reimbursement.
  • Valid Fingerprint Clearance Card.

Required Language Skills:

  • Ability to comprehend and compose instructions, correspondence and communications in English in both oral and written format.
  • Bilingual in English and Spanish is preferred, but not required.
  • Ability to effectively present information in one-on-one and small group situations to patients, internal providers and staff and other agency staff working in cooperation with the organization.


Physical Requirements:

  • Ability to frequently exert enough force to move objects weighing up to 25 pounds.
  • Ability to continuously remain in a stationary position.
  • Ability to constantly move about inside the workplace to assist patients, operate office or medical equipment, etc.
  • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, other office machinery, and medical equipment.
  • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • Ability to discern the nature of sounds at a normal spoken volume.
  • Possesses range of body motion and ability to exert enough force to lift and move adult and pediatric patients.


Other Required Knowledge, Skills, and Abilities:

  • Ability to perform medical math that may include the use of ratio/proportion, dosage calculation, metric and household equivalents, roman numerals, abbreviations, and general math including percentages, etc.
  • Ability to gather data in an organized fashion from varied sources.
  • Ability to perform a variety of assignments and make decisions requiring independent judgment.
  • Ability to resolve challenges and work under pressure.
  • Knowledge of health plans and community health centers preferred.
  • Knowledge of HIPAA rules and regulations.
  • Computer literacy required.
  • Knowledge of Electronic Health Records preferred.
  • Ability to prioritize and plan work activities, use time efficiently and develop realistic action plans.


Work Environment & Conditions:

  • Work environment is typical of a health clinic setting with occasional exposure to communicable diseases, bodily fluids and hazardous chemicals.
  • Work occasionally involves use of needles and other medical equipment with proximity to electrical current, and exposure to moving mechanical parts and some hazardous chemicals.
  • Work requires reliable transportation as position requires frequent travel and extended hours to include early mornings, evenings, and weekends.