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The Nurse Case Manager’s primary responsibility is to identify approximately 5% of the costliest/at risk membership, excluding members with non-impactable costs such as high end pharmacy and members with SPMI. The Nurse Case Manager will work with the Clinical Nurse Manager and Medical Director (lead physician) to further develop this position to best serve the needs of the patient panel and the primary care teams. 


Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patient, including in the home setting if needed; Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment; Assure that screening tests are up to date; Utilize a multi-disciplinary team approach to address opportunities to plan and coordinate care; Help to arrange contact with ancillary personnel; Establish care management plans, interventions, treatment goals – including self-management goals, and contact schedules; Promote compliance with chronic care plan; Coordinate care and communicate with multiple providers, both within and external to the practice; Review test results and tracks outcomes; Review patient compliance issues; Work one-on-one with patients and/or group visits; Leverage EMR / chronic disease registry reporting to prioritize patient follow-up; Identify and utilize cultural and community resources; Act as liaison to hospital, long-term care, specialists and home health representatives; and Utilize motivational interviewing techniques.


State of Rhode Island Board-recognized nursing education; State of Rhode Island Registered Nursing License; Minimum of three (3) years’ experience as a licensed, registered nurse, including home care clinical experience; Bilingual Spanish preferred; Previous community-based nursing experience required; Previous nursing experience in a Federally Qualified Health Center strongly preferred; Ability to work autonomously in a self-directed manner; Excellent organizational, communication and interpersonal skills; Strong Computer Skills; Experience with Electronic Medical Records required. Experience with NextGen strongly preferred; Ability to work with other interdisciplinary team members  to accomplish goals through collaboration and coordination; Positive attitude; Strong background in behavior change techniques (e.g. Motivational Interviewing, Self-Management experience, etc.); Reliable Vehicle and Proof of Insurance Required; Ability to utilize Microsoft Office Suite proficiently (Word, Excel, PowerPoint); Ability to write reports, and business correspondence; Ability to effectively present information and respond to questions from individuals or groups, managers, patients, colleagues, and the general public; Ability to define problems, collect data, establish facts, and draw valid conclusions; Ability to interpret an extensive variety of clinical documentation, procedural guidance, and eligibility requirements (managed care); Previous experience as a team player; able to work in and foster a team environment; Knowledge of provider community and community resources in the Rhode Island area; and Comprehensive knowledge of insurance company principles and outpatient delivery systems.

Salary/Benefits: Competitive salary / Excellent benefits.  Benefits include sick, vacation, paid holidays, health/dental/vision benefits, pension with employer match, life insurance and long-term disability insurance. Tri-Town is an eligible Site for the National Loan Repayment Program. 

Application Details:  

Submit Cover Letter, Resume and three (3) written letters of recommendation to Susan Connaughton, Human Resources Director at sconnaughton@tri-town.org by Friday, July 22, 2016.

Tri-Town is an Equal Opportunity Employer

For more information about applying to Tri-Town and Rhode Island in general, click here.

South County Community Action Agency  ·  1935 Kingstown Road, Wakefield, RI 02879  ·  P: 401-789-3016  ·  F: 401-515-0139
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