Nurse Care Manager - General Medicine & Geriatrics

Job description

Scheduled Hours 40 Position Summary: The Nurse Care Manager (NCM) is responsible for providing enhanced care coordination to patients attributed to WashU Medicine value-based care agreements. Primary responsibilities include providing telephonic transitional care outreach to patients recently discharged from an inpatient stay, seen in the ED for potentially avoidable treatments, or those with multiple complex comorbidities. The NCM will complete transitions of care assessments, medication reconciliation, providing disease specific education, and assisting to schedule follow-up appointments to reduce likelihood of readmission and/or avoidable ED use. Job Description: Primary Duties & Responsibilities: Care Coordination & Clinical Support Serve as the primary point of contact for medically and socially complex patients and their caregivers. Coordinate care across primary care, specialty clinics, home health, rehabilitation facilities, and community partners. Facilitate transitions of care (hospital → home, rehab → outpatient, assisted living, long-term care, hospice). Monitor chronic disease management (e.g., dementia, frailty, CHF, COPD, diabetes) and identify early signs of decompe...