Location

SAINT LOUIS, MO 63110

Scheduled Hours

40

Position Summary

The Nurse Care Manager provides expert care coordination within a dynamic, multi-site outpatient environment, moving away from bedside burnout into a relationship-based model that prioritizes long-term patient impact.

Schedule: Monday–Friday | 8:00 am – 4:30 pm.

Work life balance: No weekends, no holidays, and no on-call.

Variety: A hybrid rotation across our premier CAM, West County, and Sunset Hills clinics.

The Nurse Care Manager acts as a clinical anchor by coordinating high-risk interventions, bridging care transitions, and fostering provider-patient partnerships to resolve health hurdles and improve patient quality of life.

Job Description

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 decompensation.

• Review and triage incoming clinical messages and calls related to care coordination, patient needs or concerns requiring follow-up.

• Conduct routine check-ins in all clinic locations to support providers, staff, and patients, ensuring timely response to questions and identification of emerging patient needs.

Patient Assessment & Care Planning

• Conduct comprehensive geriatric assessments addressing medical, functional, cognitive, psychosocial, and environmental needs.

• Develop individualized care plans in collaboration with providers and the interdisciplinary team, incorporating Age-Friendly Health System principles (What Matters, Medication, Mentation, Mobility).

• Identify gaps in care, medication concerns, fall risks, cognitive decline, and safety risks; escalate appropriately.

• Support patients and caregivers managing chronic conditions by reinforcing care plans, educating on self-management, and helping navigate complex care systems.

Social Support & Resource Navigation

• Assess and address social determinants of health impacting older adult outcomes (transportation, caregiving strain, financial barriers, food insecurity, isolation).

• Connect patients and caregivers with community resources, caregiver supports, and state/local services.

• Assist with long-term care planning, home health needs, durable medical equipment, and referrals to senior services or palliative care.

• Advocate for patients and families to ensure access to appropriate services and supports.

Communication & Collaboration

• Maintain close communication with providers about patient needs, care barriers, and changes in condition.

• Collaborate with social work, nursing, pharmacy, therapy services, and community agencies.

• Participate in interdisciplinary team meetings, including GAC IDT meetings and case reviews, to discuss complex patients and adjust care strategies.

• Provide guidance and support to caregivers navigating dementia, functional decline, or other patient specific challenges.

Advocacy & Patient Support

• Serve as an advocate for patients and families navigating complex medical and social systems.

• Support caregivers managing stress, burnout, and complex care responsibilities.

• Assist with insurance or coverage questions within the scope of nursing practice.

Documentation & Compliance

• Document all care coordination activities, assessments, care plans, follow-up calls, and resource referrals in the EMR.

• Track patient progress, outstanding care needs, and follow-up items.

• Ensure communication and follow-up comply with clinic protocols, state requirements, and organizational policies.

• Identify safety concerns (e.g., potential elder abuse or neglect) and escalate per mandatory reporting guidelines.

   

Education & Problem-Solving

• Provide patient and caregiver education on medications, disease processes, self-management strategies, and available re