Registered Nurse - Care Manager (Full-time, Monday-Friday)

Job DetailsJob Location: WR Family Clinic - Eureka Spgs - Eureka Springs, AR 72632Position Type: Full TimeEducation Level: Licensed in related fieldJob Shift: DaysJob Category: Healthcare OperationsOrganization Overview, Mission, Vision, and Values

Our mission is to improve the health of people in the communities we serve through compassionate, high-quality care, prevention, and wellness education. Washington Regional Medical System is a community-owned, locally governed, non-profit health care system located in Northwest Arkansas in the heart of Fayetteville, which is consistently ranked among the Best Places to live in the country. Our 425-bed medical center has been named the #1 hospital in Arkansas for five consecutive years by U.S. News & World Report. We employ 3,200+ team members and serve the region with over 40 clinic locations, the region’s only Level II trauma center, and five Centers of Excellence - the Washington Regional J.B. Hunt Transport Services Neuroscience Institute; Washington Regional Walker Heart Institute; Washington Regional Women and Infants Center; Washington Regional Total Joint Center; and Washington Regional Pat Walker Center for Seniors. 

Position Summary

The Care Manager (CM) supports patients across the care continuum by performing nurse-led Medicare Annual Wellness Visits (AWVs), providing case management and complex care management, and driving enrollment in Advanced Primary Care Management (APCM). This role works closely with providers and clinical operations to close care gaps, improve quality outcomes, and support patients with chronic and complex needs in a value-based care environment. The CM operates within Epic and other care management platforms to document, track, and coordinate patient care activities.

Essential Position Responsibilities 

Nurse-Led Medicare Annual Wellness Visits (AWV)


Independently perform nurse-led AWVs under applicable state scope of practice and CMS direct supervision requirements
Conduct the full AWV visit, including Health Risk Assessments (HRAs), cognitive screenings, functional/safety screenings, and development of a personalized prevention plan
Review and reconcile medication lists, screening histories, and immunization status with the patient
Document the visit to meet CMS requirements for AWV billing (G0438/G0439)
Identify and close associated quality measure gaps during the visit, per established protocols
Escalate any clinical concerns to the supervising provider for review and sign-off


Case Management


Conduct patient assessments to identify medical, behavioral, and social needs
Coordinate referrals to community resources. 


APCM Enrollment


Identify patients eligible for Advanced Primary Care Management based on CMS risk stratification criteria
Educate patients and caregivers on APCM program benefits and obtain consent for enrollment
Coordinate with billing/compliance staff to ensure documentation supports appropriate service level.


Complex Care Management


Manage a caseload of patients with multiple chronic conditions, high utilization, or elevated risk scores
Develop and maintain individualized care plans in collaboration with the care team
Perform regular outreach (telephonic, MyChart, in-person) to monitor status and reinforce care plans
Provide patient and caregiver education on diagnoses, treatment plans, and self-management
Collaborate with interdisciplinary team members on complex cases
Escalate urgent clinical concerns per established protocols


Documentation & Quality


Maintain accurate, timely documentation in Epic consistent with organizational and regulatory standards
Support HEDIS and other quality measure compliance through accurate coding and gap closure documentation
Participate in quality improvement initiatives and case reviews
Track and report on productivity and outcome metrics as defined by leadership


Qualifications

Required


Current, unencumbered RN license in the state of Arkansas 
Minimum 2 years of clinical experience in primary care, case management, or care coordination
Strong understanding of Medicare AWV, CCM, and/or APCM program requirements
Proficiency with EHR systems (Epic preferred)
Excellent communication, organization, and interpersonal skills


Preferred


Experience in a value-based care or ACO environment
Familiarity with HEDIS quality measures
Case Management certification (CCM) or willingness to obtain within a defined timeframe
Experience with population health/risk stratification tools


Core Competencies


Patient-centered communication and motivational interviewing
Time management across a mixed caseload (scheduled visits, telephonic outreach, documentation)
Critical thinking and clinical judgment for escalation decisions
Collaborative, team-based approach to care delivery
Comfort with data tracking and quality metric reporting


 

Wor