Job Description

Job Title:                       Nurse, Care Management

Reports To:                   Manager, Nurse Program

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:

The requirements listed below are representative of the knowledge, skill, and/or ability required.  The job description duties may be updated at any time based on the business need.


Essential Job Duties:

  • 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.
  • Monitor’s 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 patients, family/caregiver(s), care team, payers, and community resources, as needed.
  • Assist care team in the administration of patient care for care managed patient, and as back up for medical support staff with assigned panels.


  • 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 assigned providers Panel.
  • Completes pre-visit planning to identify needs for care management services.
  • Completes provider orders for procedures that require advanced clinical and/or nursing skills.
  • Provides patient education as directed by provider and within scope of practice.
  • 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.
  • Documents and maintains records of verbal and written procedures, medication, delivery of care, and pertinent information regarding patient care services.
  • Complies with infection control policies and protocols; follows medication administration, storage procedures and controlled substance regulations.
  • Ensures operation of medical equipment by completing preventive maintenance requirements, following manufacturer’s instructions, reporting malfunctions, requesting repairs, maintaining equipment inventory, and evaluating new equipment and techniques.
  • Performs lab draws, conducts CBC analyzer tests, and maintains laboratory documents when needed.
  • Schedules patients for appointments under approved CCHCI guidelines.


Additional Job Duties:

  • Takes incoming calls from patients who have questions regarding medication refills or prior authorizations.
  • Refill’s medications if appropriate and under approved standing orders
  • Reviews all incoming Transition of Care/Referral Documents received as Consolidated Clinical Document Architecture (CCDA’s) and reconciles medication lists and active diagnoses as appropriate per assigned provider.
  • Notifies providers of new diagnoses or changes in medication regimens when appropriate for assigned provider panels.


Required Education, Experience, Certificates & Licenses:

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


Preferred Education, Experience, Certificates & Licenses:


  • Current Unrestricted Arizona State Nursing RN license preferred.
  • Experience in a clinical setting preferred.


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 computers, 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 a 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.
  • 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 the position requires frequent travel and extended hours to include early mornings, evenings, and weekends.