**Clinical Excellence** **FT/ 80 hours per pay** **Summary of Position** The RN Care Manager will provide a systematic organization of care with the Physician Practice and will coordinate with other care team members and/or settings. The RN Care Manager will provide high quality, patient centered care management to patients identified as needed by high-risk registries. This will include, but is not limited to developing individualized care plans, care coordination across the continuum, prevention plans, and ongoing monitoring. The RN Care Manager will take a lead role in assuring the care team is informed of the overall care plan, progress and needs. **Nature and Scope** Care Management results from a complex exercise of clinical judgement, occurs through a relationship-based engagement with the care team, and addresses the patient’s identified health care goals. Essential functions include: + Documentation of a mutually agreed upon plan of care based on patient’s goals, addressing all significant ongoing health problems and risks. + Provide ongoing assessment, monitoring, and tracking in E H R. Care will be managed by the use of a registry functionality with interventions triggered by regular review and monitoring. + Provide proactive care and education outside the routine office visit, for example by phone, Patient Portal, or other access activities. + Build a trusting, professional relationship with the patient, family, and/or caregivers. + Utilize self-management and shared decision-making tools. **Qualifications** 1. BSN required. 2. Maintain current RN licensure as issued by the State of Ohio Board of Nursing. 3. A minimum of three years’ previous nursing experience required; leadership role preferred. 4. Solid knowledge of chronic conditions, strong assessment, and patient interview skills. 5. Demonstrate accurate and timely data and computer skills. 6. Excellent written and verbal communication skills. 7. Must be self-directed with the ability to work independently. 8. Ability to prioritize projects, and multi-task as appropriate. 9. EPIC knowledge preferred.