Healthcare

Care Manager Registered Nurse

RemoteRemoteFull TimeManager / HeadPosted 11 days ago

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Required skills

Care Manager Registered Nurse
remote case management
High-Risk Huddle
avoidable admissions
emergency department utilization
clinical outcomes
patient experience
care continuity
patient-centered care
panel management

Nice to have

behavioral health
community-based organizations
team huddles
case reviews
interdisciplinary care discussions

Role summary

Hopscotch Primary Care is seeking a Care Manager Registered Nurse (CMRN) to manage a panel of high-acuity patients primarily through remote case management with some in-clinic support. This hybrid role focuses on reducing hospital admissions and ED visits, improving clinical outcomes and patient experience, and ensuring care continuity. The CMRN collaborates with providers and care teams to develop and update care plans, conduct telephonic outreach, and coordinate care across the healthcare continuum. Responsibilities include clinical collaboration, managing quality and utilization metrics, supporting complex patients in-clinic, assessing social determinants of health, and engaging patients/families. The role requires adherence to care management protocols and continuous improvement of workflows. A minimum of 2 years of care management experience and an active NC RN license are required.

About Hopscotch Primary Care

At Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities. Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities. We are on a mission to transform healthcare in rural America. We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most.

Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch. Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time.

Today, we are serving thousands of patients in our value-based care model and the number is growing every day. If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we’d like to meet you.

ABOUT THE ROLE

The Care Manager Registered Nurse (CMRN) is a hybrid role responsible for managing a panel of higher-acuity patients (HPP) through a combination of primarily remote case management and targeted in-clinic support, such as High-Risk Huddle meetings.

This role is accountable for end-to-end care management, with a strong focus on:

Reducing avoidable admissions (ADK) and emergency department utilization (EDK)

Improving clinical outcomes and patient experience

Supporting care continuity across the healthcare continuum

The CMRN partners closely with providers, clinic staff, and Care Center Managers (CCMs) to deliver coordinated, proactive, and patient-centered care. This position is primarily remote, with regular in-office presence based on patient or program needs.

Specific responsibilities for this role will include, but are not limited to:

Panel Management & Care Coordination (Primarily – Remote)

Manage a defined panel of high-risk patients, delivering comprehensive, longitudinal case management

Develop, implement, and continuously update individualized care plans in collaboration with providers and care teams

Perform ongoing telephonic outreach and monitoring to improve patient outcomes

Coordinate care across the patients HPC provider, specialists, hospitals, EDs, SNFs, and community resources

Partner and collaborate with transitions of care team, for a smooth transition and to ensure that the patient needs are met following the transitions of care period

Clinical Collaboration & Outcomes Management

Partner with providers, MAs, LPNs, and Care Center Managers to align on patient care plans and priorities

Escalate clinical concerns and barriers to care in real time

Participate in team huddles, case reviews, and interdisciplinary care discussions

Track and improve quality and utilization metrics tied to patient outcomes

In-Clinic Responsibilities (Hybrid Component)

Maintain in-office presence minimum of 1 time a month and as needed to:

Support high-risk patient visits

Assist with care coordination for complex patients

Home & Community-Based Support

Coordinate with in office LPN for occasional home visits for high-risk or complex patients when clinically appropriate

Assess social determinants of health, home safety, and barriers to care

Coordinate community-based services and resources to support patient care plan goals

Patient & Family Engagement

Build trusted relationships with patients, families, and caregivers

Provide education on disease management, medications, and care plans

Utilize motivational interviewing and coaching techniques to drive behavior change

Program Quality, Compliance & Best Practices

Adhere to care management protocols, regulatory requirements, and documentation standards

Support continuous improvement of care management workflows and outcomes

Identify and report gaps, risks, or adverse events

Contribute to development of best practices, training, and process improvements

ABOUT YOU

You would be a great fit for this position if you have a minimum of 2 years of experience as a care manager embedded into an interdisciplinary team and the following:

Active registered nurse (RN) license in North Carolina

BLS certification

Experience working in a primary care clinic focused on chronic disease management

Experience with behavioral health and community-based organizations preferred

Experience with motivational interviewing, behavior change, health promotion, and coaching

Strong verbal and written communication skills and customer service orientation

From a cultural perspective, you are:

Patient-first, team-oriented

Agile and thoughtful in a fast-paced environment

Solutions-driven, always looking to improve

Accountable, with high standards for yourself and others

Hands-on and collaborative across diverse teams

Clear, concise communicator who follows through

Positive, assuming good intent

Customer-focused, with a passion for serving patients and providers

At Hopscotch Primary Care, we embrace diversity, invest in a culture of inclusion and positivity and encourage all to apply to join our team. You will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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