Care Manager (RN)

Are you ready to join a passionate community of people who are changing how health care is delivered? A place where you will find a career you love while truly making a difference building healthier communities. If this sounds like you, we would love to have you apply as Care Manager (RN), with Medical Home Network! Founded in 2009 by the Comer Family Foundation, Medical Home Network unites health systems and providers around a vision to improve the health of patients and communities in Chicago. Today, as a Public Benefit Corporation (PBC), MHN has expanded its mission and impact to new markets and is a nationally recognized leader in transforming care within the safety net and building healthier communities across the country. Our whole person model of care, powered by proprietary technology, enhances collaboration across primary care and community-based organizations, leading to better outcomes, lower costs, and reduced health disparities.

We are seeking a compassionate and experienced Care Manager (RN) to join our care team, specializing in the coordination and management of patients with chronic and complex health conditions. This role is ideal for a nurse with a strong background in CHF, CKD, COPD and DM disease management, care coordination, and experience working within Federally Qualified Health Centers (FQHCs) or similar community-based healthcare settings. This position is responsible for coordinating screenings and assessments, developing and implementing individualized care plans, and supporting patients throughout their care journey. In collaboration with contracted health centers, the Care Manager provides billable chronic care management services and supports MHN’s care delivery initiatives. This role also involves guiding and supporting care management efforts across the organization, promoting best practices, and ensuring patients receive comprehensive, compassionate care. The Care Manager reports to the Associate Medical Director. THE PERKS Fun, challenging, and collaborative work environment with passionate colleagues that care deeply about healthcare delivery. Recognized as One of the Best Places to Work in Healthcare by Modern Healthcare. Competitive benefits programs including Medical, Vision, Dental, HSA, FSA, and 401k. Fitness reimbursement, commuter benefits, and tuition assistance. Great work life benefits- Paid time off, sick time, and 12 paid holidays. Remote Schedule- 25% travel to primarily OK and IL, possible other markets in the future.

Utilize evidence-based protocols and clinical guidelines to manage high-risk populations effectively, specifically for but not limited to CHF, CKD, DM, and COPD/asthma. Deliver patient-centered care management to individuals with multiple chronic conditions, ensuring continuity and quality across the care continuum. Develop, implement, and monitor individualized care plans in collaboration with interdisciplinary teams. Provide education and support to patients and families on disease processes, medication adherence, lifestyle modifications, and self-management strategies. Coordinate care transitions, including hospital discharges and specialist referrals, to reduce readmissions and improve outcomes. Engage in proactive outreach and follow-up to ensure patients remain engaged in their care plans and with their primary care team. Document all care activities accurately and timely in the electronic health record (EHR) and/or care management platform. Participate in quality improvement initiatives and closing care gaps. Supervise care coordinator’s Chronic Care Management (CCM) care plans and provide licensed oversight and approval. Provide education and training, as necessary, to care coordinators, care managers and other care team members.