Chronic Care Nurse Manager (RN)

January 2, 2019

Essential Functions:

Care Coordination, Care Management and Transitions of Care

  • Patient care coordination and care management, including: care transitions; referrals; report management; and two-way communication between the Primary Care Physician (PCP), specialists, and other providers.
  • Support the Assistant Director of Population and Community Health in developing and implementing population health initiatives and integration into the Center’s activities through practice transformation and development of initiatives to improve clinical outcomes.
  • Supervise transition of care for patients discharged from the hospital or ER within 24 – 48 hours to prevent readmission and related complications. Evaluate and provide appropriate follow-up care for recently discharged patients to prevent further disease exacerbation, complications, or additional ER or hospital utilization.
  • Supports the clinical department in implementing and coordinating population health initiatives and support services for high-risk patients.
  • Use data from the electronic health record to determine patients at highest risk for health deterioration, sentinel events, and/or poor outcomes.
  • Supervise timely and ongoing communication with the PCP and practice team regarding their highest risk patients to maximize the management of patient needs and ensure that risk reduction activities are incorporated into the care plan.
  • Oversight of the Center’s Health Homes Program. Coordination with Network staff on meeting deliverables, creating strategies and ensuring proper documentation, billing, and reporting is occurring. Recruitment, supervision, and training of Health Home staff.
  • Support of various grant funded projects and program initiatives
  • Assist Clinical care manager with daily operations as needed.
  • Assist with Center operations as Administrator on Duty (AOD) during evening hours and on Saturdays as needed.
  • Other duties as assigned

Clinic Patient Care

  • Assist with day-to-day patient care activities and tasks as needed. These will include but are not limited to: processing PCP forms such as prior authorization (PA), M11Q, home care orders, transportation and durable medical equipment (DME) device requests; patient education (focus on Diabetes and Hypertension teaching); pre-visit planning; post-visit planning; pre-natal follow-up; medication administration; redirecting patients to appropriate services such as patient navigation and attend daily huddles.

Collaboration and Committee Involvement

  • Participate in Quality Improvement (QI) and Performance Improvement (PI) initiatives, including attendance at meetings, data input, and organization of project data and development of reports.


  • Outreach in the community, participate in health fairs and occasional home visits.


Minimum Required Qualifications:

  • Bachelor’s Degree in Science (BSN)
  • Two years’ experience in ambulatory setting (health center, emergency room or large practice).
  • Must be knowledgeable about Patient Centered Medical Home guidelines and other regulatory standards.
  • Demonstrated track record of organization, focus and ability to work in a fast-paced clinical setting.
  • Working experience with electronic medical records software.
  • Computer literacy in a Microsoft environment: MS Outlook, Word and Excel.

Preferred Qualifications:

  • Master of Science (MSN)
  • eClinicalWorks experience.
  • Bilingual: English/Spanish.

Licenses and/or Certification Required:

  • Valid Registered Nurse License in New York State.
  • Valid BLS Certificate

How To Apply

Please forward resume by email to, and reference the job title in the subject line.