Website Tri-County Family Medicine

Caring for Our Communities

RN Care Managers at TCFM serve the most vulnerable people in our community!

Main Function:

A Registered Nurse, works together with a care team to identify and proactively manage the care needs of high-risk patients within the primary care practice setting.

The Care Manager provides assessment, care coordination, advocacy, and coaching for identified patients at risk for hospital admissions or emergency room visits.

The Care Manager uses team collaboration to identify at-risk patients and determines the drivers of risk in conjunction with the patient, family, physician, and ancillary health providers. An integral, professional member of the care team, the Care Manager measures the impact of care coordination interventions,
through lifestyle changes/behavior and regularly reassesses the patient’s risk for incurring adverse health outcomes.

Reports To: Practice Manager

Duties and Responsibilities:

  • Provides Care Management services under the direction of the provider:
  • Identify or work with others to identify patients with a high risk of adverse health outcomes such as death, disability, In-patient admission, Skilled Nursing Facility (SNF) admission, or Emergency Department (ED) visit.● Establish trusting relationships with patients, enabling effective intervention and support.
  •  Conduct assessments of patient condition, needs, preferences, and clinical and psychosocial barriers.
  • Support the patient in the identification of actionable goals to optimize health outcomes.
  •  Develop a plan of care that promotes improved healthcare outcomes and quality of life informed by the patient’s goals, strengths, and barriers.
  • Implement the patient-approved plan of care in collaboration with the patient through the practice’s care team, community and home-based visits, and telephonic support.
    •  Provide comprehensive Care Management including self-management support, health promotion, connection/referral to appropriate physical, mental health, or substance abuse providers as well as community-based organization social supports to decrease the barriers that prevent the patient from attending appointments and following the plan of care.
  • Utilize self-management support interventions to promote self-advocacy.
  • Monitor the patient’s level of activation relative to their health goals over time.
  • Advocate for patients to ensure access and timely service delivery across the continuum of care and community resources.
  • Provide patients/caregivers with information in support of care plan goals.
  •  Optimize patient access to needed services through insurance and other benefits.
    • Facilitate care coordination with primary or specialty medical care as well as acute and outpatient medical, mental health, and substance abuse services, and other Care Managers involved in supporting the individual.
    •  Provide culturally competent interventions based on patient assessment and identified cultural needs.
    •  Provide comprehensive transitional care with an emphasis on coordination of care and services post-critical events such as ED admittance, hospital inpatient admission, and discharge, or Skilled Nursing admission and discharge.
  • Work with attending/consulting physicians to facilitate effective transitions through the timely communication of information necessary for patient care and discharge planning, and supporting appropriate patient self-management.
    • Develop an intervention plan that addresses events such as ED visits, inpatient admissions, or other crisis events.
    • Ensure the planned crisis interventions are effective and result in necessary modifications to the plan of care and that additional supports are needed and added if necessary for support services.
    • Conduct medication reconciliation as appropriate and communicate the need for adjustment to the care team/provider.
    •  Provide patient education.
    • Facilitate solutions to patient care delivery problems.
    • Work with the family/caregiver to assess needs, discuss burdens and provide support.
    • Ensure language access/translation capability.
  • Modify goals and Care Management interventions as appropriate to the needs/progress of the individual.
  •  Share information such as progress, barriers, and new conditions with the practice team members and other care providers as necessary.
  • Participate in patient care team meetings and reviews.
  • Meet practice policy and procedures related to documentation through a software tool of Care Management activities and their effectiveness.
  • Handle confidential information in accordance with HIPPA as well as state and federal privacy and confidentiality rules.

Participates as a member of the Care Team:

  • Participates effectively as a Care Team member within the practice by:
    • Foster a working relationship with patients, providers and practice staff.
    • Work effectively with others to coordinate patient and access care support services.
    • Provide input relating to changes that may enhance the practice effectiveness.
    • Participate in meetings and huddles as appropriate.
    •  Conduct pre-visit planning and post-visit follow-up for Care Managed patients.
    •  Provide feedback to providers regarding patient progress and barriers encountered.
    • Prepare for and participate in case review meetings to share cases, discoveries, and concerns and collaborate in the development of plans of care.

Interactions with outside agencies:

  • Attend team meetings, training, ongoing skill development events, and other functions as required.
  •  Collect and provide reports of activities as required.
  •  Share updated information related to appropriate community resources.
  • Participate in all scheduled meetings and training opportunities, as able. Other functions and responsibilities:
  • Identifies opportunities to improve processes and services.
  • Shares with practice and leadership issues that are obstacles to meeting patient needs.
  • Performs other duties as assigned.

Position Qualifications:

  • Excellent communication skills and ability to form collaborative partnerships across all service settings.
  • Working knowledge of the provision of health care in a variety of settings.
  • Knowledge of community resources is preferable.
  • Ability to assimilate new information and technologies into daily work.
  • Competent in Microsoft Office products such as Word, Excel, Outlook, and PowerPoint.
  • Ability to engage and build relationships with patients.
  • Ability to prioritize your workload and assess the need for collaboration with the health care team.


Graduate of an approved school of nursing with an RN license to practice in NYS, or MSW. Must maintain a current and valid registration certificate. Experience: 3-5 years of clinical nursing or social work experience, preferably with 3-5 years of community health experience, with an adult population.


Patients and family, staff, physicians, sales persons. Physical Demands: Standing and walking most of the day, pushing, pulling, reaching, and lifting medium and heavy weights occasionally.

Working Conditions/Hazards:

Exposure to communicable diseases, back strain, and minor injuries from cuts.


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