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Position Summary

The RN Care Manager is responsible for applying the nursing process, evidence-based practice, and care management principles to support heart failure patients enrolled in the Heart Failure Bridge Clinic. This role focuses on outreaching to high-risk patients, coordinating care across settings, supporting medication and symptom management, and fostering patient engagement and self-management.

The RN Care Manager collaborates closely with physicians, pharmacists, social workers, care coordinators, and administrative staff to ensure seamless transitions of care and to address medical, behavioral, and social needs that influence health outcomes.

Principal Responsibilities and Tasks

Clinical Assessment & Critical Thinking

Apply the nursing process and evidence-based standards to assess patient needs and guide care planning.

Evaluate clinical, psychosocial, and environmental factors impacting heart failure management and recovery.

Identify patients who may benefit from telephonic and virtual outreach and initiate care management interventions.

Participate in remote patient monitoring and support self-management skills.

Population Health & Care Management

Analyze utilization patterns including inpatient admissions, ED visits, readmissions, and high-cost utilization.

Develop population-based strategies to improve quality, reduce avoidable utilization, and enhance patient engagement.

Manage active cases based on acuity and intensity, ensuring timely follow-up and escalation when needed.

Transitional Care & Coordination

Track and support transitions of care, ensuring "warm handoffs" between hospitals, emergency departments, clinics, and community settings.

Coordinate follow-up appointments, diagnostic testing, and referrals to pharmacy, behavioral health, and specialty services.

Facilitate communication among all members of the care team to minimize fragmentation and ensure continuity.

Patient Engagement, Coaching & Education

Establish collaborative partnerships with patients and caregivers to support self-management, lifestyle changes, and adherence to treatment plans.

Educate patients on heart failure management, medication adherence, symptom monitoring, and available community resources.

Advocate for patients and help them navigate medical, behavioral, and social service systems.

Social Determinants of Health

Screen for SDOH barriers and connect patients to community resources addressing transportation, food insecurity, housing, medication access, and more.

Consult with external agencies to coordinate support services.

Documentation, Compliance & Quality

Document all assessments, interventions, and communications in the EMR and care management platforms.

Participate in chart audits, quality reviews, and program evaluation activities.

Ensure compliance with federal and state regulations, case management standards, and HIPAA requirements.

Report critical incidents and quality-of-care concerns promptly.

Team Leadership & Collaboration

Work collaboratively with physicians, pharmacists, social workers, care coordinators, and administrative leaders to design and implement care management protocols.

Provide mentorship and clinical guidance to chronic disease care coordinators and other team members.

Delegate appropriate tasks to support staff while maintaining oversight of patient outcomes.

Participate in special projects and contribute to program development.

Education and Experience

Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required; BSN preferred.

3 to 5 years of care coordination experience and/or experience working in an outpatient ambulatory setting

Experience with educating patients and patient goal setting (essential)

Case Management Certification (preferred)

Experience in a manage care information environment (preferred)

Preferred experience would include knowledge of quality improvement processes (LEAN or PDSA); practice re-design work such as patient centered medical home and Joint Commission and National Committee for Quality Assurance (NCQA) accreditations.

Knowledge, Skills and Abilities

Knowledge and experience with managing and overseeing the comprehensive assessment, planning, implementation and overall evaluation of individual patient needs

Proficient analytical, organization, and problem-solving skills to identify opportunities, to implement efficient work processes as it relates to case management

Proficient documentation skills to maintain client records

Ability to work effectively in a stressful work environment and handle confidential issues with integrity and discretion

Critical thinking skills to analyze and solve problems

Strong problem management strategies and issue resolution skills

Excellent interpersonal, verbal, and written communication skills

Strong organization skills, detail oriented, and knowledgeable Ability to work independently and effectively in a fast pace environment. Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.

Ability to effectively present information and respond to questions from families, members, providers, and clients, as well as the ability to relate effectively to upper management

Ability to work independently, handle multiple assignments, establish priorities, and demonstrate high level time management skills Understands benefit/payer systems and reimbursement structures for patients.

Strong clinical knowledge of broad range of medical practice settings and healthcare delivery systems

Thorough and solid knowledge of health care and managed care delivery systems. This includes standards of medical practice, insurance benefits structure, and the utilization and case management process.

Knowledge of state and federal laws and resources

Proficiency in Microsoft Office including Outlook, Word, Excel and PowerPoint; knowledge of or the ability to learn care management/EMR software (e.g., Epic) and other software in order to perform job duties

This role is funded for an initial two-year period through a grant. Renewal is possible if future funding is secured; however, continuation beyond the grant period cannot be guaranteed.