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Chronic Care Nurse Manager (RN)- Ryan Chelsea-Clinton

September 29, 2020

Position Overview:

The Chronic Care Nurse Manager is an integral member of the Center’s primary care practice team and is responsible for providing care coordination and care management services to patients who are at risk for poor outcomes, health deterioration, co-morbidities and preventable hospitalizations. This includes coordinating and managing the care of chronically ill patients and ensuring that patients receive optimal care in relation to acute illness management, chronic disease management, and preventive care across multiple health settings and with various multiple physicians/providers. This role provides supervision and oversight of population health staff. This work is carried out in support of the mission and goals of Ryan Health.

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 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

Competencies Required:
Customer Service:

  • Professional, courteous and respectful attitude in dealing with patients
  • Demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served (if applicable).
  • Commits to exceeding expectations of the patient


  • Works well with others
  • Contributes input to improve outcomes
  • Asks others for opinions and feedback, provides feedback in a tactful respectful way

Minimal Training Time:

  • Six months of actual workdays’ introductory period.

Working Conditions:

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to stand, sit, talk and hear.

The employee is occasionally required to move about the office; use hands and fingers to feel, handle, or operate office equipment.

Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work is primarily in a general primary care setting, which includes the unpredictability in behaviors of individuals, and acute and chronic infectious diseases, which may be contagious. Adequate preparation and precaution is necessary.


The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position. This position may be required to perform other duties. If such work becomes a permanent and regular part of the job, a new description will be prepared.

Equal Opportunity Employer

Ryan Health is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, gender identity, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.

How To Apply