​Job Title: Registered Nurse Care Manager – PCHH

Department: Medical

Reports To: Clinical Director – Medical

FLSA Classification​: Salary/Exempt

Starting Salary: $60,000

Full-Time: M-F 8:00 – 4:30

Revision Date: 01-16-23



As a Registered Nurse Care Manager, employee will serve as a integral part of our GMHC team to provide excellent patient care to those within our service areas.  Employee will work to assess the immediate and preventative care needs of our patients to ensure the overall health and wellbeing of our patients.  Provide case management services utilizing the standards set by Primary Care Health and Home.

Essential Functions:

  • Adhere to patient confidentiality.
  • Foster direct relationships with patients and coordinate with primary care team, specialty care teams, and inpatient facilities.
  • Conduct intake interviews with patients, including enrolling and/or referring patients into primary care for preventative services and chronic disease management.
  • Assess patients for barriers to their care and develop care plans that are patient driven, documented in EMR, and updated at least once per year.
  • Follow-up with patients via phone calls, home visits and visits to other settings where patients can be found.
  • Help patients set self-management goals in coordination with the care team and community partners.
  • Utilize MO HealthNet health technology programs and initiatives.
  • Address medical alerts, hospital admissions/discharges, and ER visits – Including medication reconciliation.
  • Identify and address high utilizers.
  • Provide leadership for the implementation of and coordination of health home activities.
  • Coordinates activities of health home staff.
  • Champions practice transformation based on health home principles.
  • Monitors health home performance and leads improvement efforts.
  • Facilitates training and technical assistance.
  • Monitor and report performance measures and outcomes monthly.
  • Monitor staff: enrollee ratios to ensure staffing meets MO Healthnet requirements.
  • Attend monthly/quarterly meetings as required by supervisor to discuss patient care to eliminate duplicative efforts and identify resources to support patients.
  • Order supplies for PCHH.
  • Perform other duties as assigned.

Physical Demands:
Be able to sit, stand, and work in uncomfortable conditions for short amount of time, as well as able to lift to 50 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.

Definitions for OSHA working environment are:

Category I — Involves routine exposure to blood or body fluids.

Category II – Involves possible exposure to blood or body fluids.

Category III – Involves no exposure.

OSHA category for this position is Category II.

 Required Knowledge, Skills, and Experience:

  1. Obtain and maintain a valid RN or LPN license in the State of Missouri.
  2. BLS certification required.
  3. Must possess a valid Driver’s License, and proof of insurance for personal vehicle used for business.
  4. Operate a personal computer and calculator.
  5. Problem solving: Frequent problems arise in this positions that are outside established policies or bodies of knowledge calling for high-level skills in problem solving.
  6. Decision Making: Frequent problems arise in this position calling for careful and analytical judgment.
  7. Interpersonal: Must interact regularly with patients, employees, and administration.


  • Problem Solving–Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
  • Interpersonal Skills--Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others’ ideas and tries new things.
  • Teamwork–Balances team and individual responsibilities; Exhibits objectivity and openness to others’ views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone’s efforts to succeed.