Telephonic Nurse Care Manager

At AMC Health, we deliver advanced virtual caregiving through a whole-person, data-driven approach. Our mission is to improve clinical outcomes and health equity by combining compassionate care with real-time data, advanced analytics, and innovative technology. We empower clinicians to practice at the top of their license while helping patients heal safely and comfortably at home.

The Telephonic Nurse Care Manager is responsible for the remote, telephonic management of patients with chronic and complex conditions (including but not limited to CHF, COPD, diabetes, and hypertension). This role partners closely with patients, caregivers, and interdisciplinary care teams to assess health status, develop and implement evidence-based care plans, monitor biometric and IVR data, and intervene proactively to reduce risk, prevent escalation, and improve outcomes. This is a remote position requiring strong clinical judgment, excellent communication skills, and comfort working in a technology-enabled, fast-paced virtual care environment.

Conduct comprehensive telephonic and virtual clinical assessments, including review and interpretation of biometric, RPM, and IVR data with trend analysis Develop, implement, and adjust individualized nursing care plans aligned with patient goals, evidence-based practice, and organizational protocols Engage patients using Motivational Interviewing techniques to drive behavior change, adherence, and self-management Identify clinical risks, changes in condition, and urgent situations; escalate appropriately and in accordance with clinical guidelines Collaborate with interdisciplinary care teams (internal and external) to coordinate care, referrals, and transitions across the continuum Deliver proactive interventions aimed at reducing hospitalizations, ER visits, and overall cost of care Document all patient interactions accurately, timely, and comprehensively in the electronic health record (EHR) Participate in quality improvement initiatives, chart audits, and performance reviews to enhance clinical outcomes and care delivery Perform care management activities in alignment with client-specific workflows, performance expectations, and service-level requirements Maintain compliance with all clinical, regulatory, HIPAA, and organizational standards