Job Type

Full-time

Description

Compensation:

• Non-exempt/Hourly
• Standard wage range is $40.25 to $49.32 per hour
• It may be possible to earn more over time up to $58.33 per hour
• Eligible for a Saturday shift differential

Work Schedule:

• 40 hours per week
• Shifts available for four 10-hour days or five 8-hour days Monday-Friday
• Participation in Saturday rotation with schedule of 10am-3:00pm
• Shifts may change occasionally based on patient access and organizational needs

Job Summary:

The RN Care Manager is responsible for providing proactive, population-based, patient-centered care management to a defined panel of patients within a team-based primary care model. This role focuses on chronic disease management, preventive care gap closure, transitions of care, and patient self-management support. The primary duties and responsibilities include:

1. Panel Management & Care Coordination

a. Performs direct patient care and RN-driven care management for empaneled patients from prioritized patient populations.

b. Collaborates with Medical Leadership in identifying priority populations and defining entry and exclusion criteria.

c. Conducts proactive and regular outreach using registries, reports, and risk stratification tools

d. Coordinates care across the care team, including providers, MAs, behavioral health, pharmacy, case management, referrals, and external partners

e. Keeps patients' primary care provider informed on progress, needs and potential barriers

f. Serves as consistent point of contact for patients enrolled in care management

2. Chronic Disease & Preventive Care Management for empaneled patients

a. Enrolls eligible patients in and discharges patients from care management based on established criteria

b. Monitors disease-specific outcomes (e.g. blood pressure, HbA1c) and intervenes using approved protocols and standing orders

c. Identifies and closes preventive care gaps (e.g. screenings, labs, immunizations)

d. Provides patient education, coaching, and goal setting using motivational interviewing techniques

3. Transitions of Care for patients enrolled in Care Management:

a. Completes hospital and emergency department follow-up outreach within established timelines

b. Performs medication reconciliation and symptom assessment post-discharge

c. Coordinates follow up appointments, labs, and referrals to reduce readmissions and care fragmentation

4. Care Planning & Documentation

a. Develops and maintains individual, person-centered care plans in collaboration with patients and providers

b. Screens for social drivers of health, depression, anxiety, and barriers to care

c. Ensures all care plans include targeted completion dates and timelines for monitoring and follow-up

d. Meets with patients in accordance with their care plan and documents all care management activities accurately and timely in electronic health record

e. Uses standardized documentation tools, templates, and workflows consistent with Patient Centered Medical Home requirements

5. Quality & Program Development:

a. Participates in quality improvement initiatives and supports achievement of quality goals related to care management

b. Plays a lead role in the development and refinement of RN care management protocols and workflows

c. Tracks and reports care management metrics as assigned

d. Collaborates with leadership to evaluate program effectiveness and opportunities for expansion

What We Offer:

• A friendly and collaborative team environment
• A competitive compensation package
• Outpatient clinic - no hospital work
• Day shifts only - no nights
• No Sunday shifts

Loan Repayment Application Opportunities

• Employment at UCNW counts towards eligibility for Public Service Loan Forgiveness - details can be viewed at Federal Student Aid .
• Eligible providers may apply for loan repayment through the Washington Student Achievement Council ( Washington Health Corps | WSAC ) &/or Nurse Corps Loan Repayment Program ( Apply to the Nurse Corps Loan Repayment Program | Bureau of Health Workforce (hrsa.gov) )

While employes at UCNW are eligible to apply for these loan repayment awards, receipt is not guaranteed.

Generous benefits including:

• Medical, dental, & vision insurance
• 401(k) retirement plan with employer match after 1 year of eligibility
• 6 paid holidays
• Generous paid time off of 108 hours accrued in Year 1, 156 hours accrued in Year 2 and gradually increasing to 196 hours accrued per year over 10 years
• Paid sick leave accrued at 1 hour per 40 hours paid
• Other paid leaves for Bereavement, Jury Duty & Bone Marrow/Organ Donation
• Life/Accidental Death & Dismemberment (AD&D) insurance
• Variety of optional insurances including Supplementary Life/AD&D, Short Term and Long Term Disability, Critical Illness, Accident, and Travel as well as Identity Theft Protection
• Flexible Spending Account
• Self-funded Health Savings Account on Base Medical Insurance Plan
• Employee Assistance Program
• Alternative transportation incentives
• Healthy Living reimbursement
• Unique programs including Medical Hardship Payroll Loans, Employee Referral Bonuses & Will preparation services
• Continuing Education (days & funds)
• Reimbursement of Washington State license renewal fees

Requirements

• Knowledge and training in the field of Nursing typically acquired through a formal BSN degree program
• Washington State RN License
• Ambulatory Care Nursing Board Certification (view details at Ambulatory Care Nursing Certification (AMB-BC™) | ANA ) - if not currently certified, must obtain within first year of employment and we'll reimburse the certification exam fee after passing the exam
• At least one year demonstrated experience in care management, care coordination, or population-based nursing (e.g. chronic disease management, transitions of care, preventive outreach)
• Strong clinical assessment, care planning, and patient education skills
• Basic Life Support (BLS) Certification (can get certified when starting)
• Ability to use the following software: Microsoft Outlook, Microsoft Word, Electronic Medical Records (we use Epic), patient scheduling system, HR/Payroll program for timesheets, training systems and SharePoint.
• Ability to understand and respond effectively and with sensitivity to special population groups, including those defined by race, ethnicity, language, age, gender, sexual orientation, economic standing, and others.
• Ability to work at both our Bellingham and Ferndale locations on a regular basis

Preferred Qualifications

• At least two years' experience with outpatient clinic responsibilities
• Ability to communicate bilingually in English & Spanish a plus.

Qualified candidates who meet the requirements who have applicable experience or similar qualifications are encouraged to apply!

About Bellingham & Ferndale

Live in a community consistently rated as one of the most desirable in the USA! Nestled on Bellingham Bay at the foot of the Cascade Mountains just a short distance from Seattle, Vancouver BC, and the San Juan Islands, Bellingham is home to over 90,000 people and surrounded by several charming small towns. Set amidst lush farmland on the Nooksack River with a commanding view of Mount Baker, Ferndale's 15,000+ residents pride themselves on their relaxed, small-town friendliness and affordable quality of life. Ferndale's convenient location in Whatcom County on the I-5 corridor is just 15 minutes away from our main site in beautiful downtown Bellingham. Enjoy all the area has to offer:

• Recreational & Outdoor Activities (Hiking, Biking, Skiing, Snow Boarding, Fishing, Sailing, Kayaking, & Camping)
• Excellent Schools (University, Community College, Technical School, & Outstanding K-12 Educational System)
• Small Town or City Living (Unique Shops, Local Festivals, Farmers Markets, Berry Picking, & Community Events)
• Cultural Activities (Theater, Music, Independent Films, Museums, Art Studios, & Diverse Local Restaurants)

To Apply

Visit our Careers Page at www.unitycarenw.org . For news on our organization & future job postings, please follow us on LinkedIn at https://bit.ly/363mfhv !

If you feel this job posting is missing any required compensation or benefit information, please contact [email protected]. Other questions can be addressed throughout the recruitment process for candidates selected to move forward.

Unity Care NW has an Employee Health Program for the safety of our patients and staff. The program requires all new employees to have up to date vaccines for influenza and strongly encourages up to date vaccines for COVID-19. More information about this program is provided throughout the recruitment process.