Posted Tuesday, June 24, 2025 at 5:00 AM
Job Summary:
The Chronic Disease Management Nurse is responsible for providing care management services to patients with complex chronic medical conditions. The patient population may include those with socioeconomic and mental health co-morbidities. The goal of the program is to assist these patients to achieve optimal health and/or independence in managing their care. To achieve this goal, the disease manager will demonstrate and apply knowledge of the philosophy/principles of comprehensive care management, patient centered, culturally sensitive care coordination and management of complex patients. This position will work closely with members of the care team to achieve goals/objectives, standards of performance, regulatory compliance, and quality patient care.
Duties/Responsibilities:
Assess the physical, functional, social, psychological, environmental, learning and financial needs of patients.
Identify problems, goals and interventions designed to meet patient’s needs surrounding management of complex chronic medical conditions, including prioritized goals that consider the patient/caregivers goals, preferences and desired level of involvement in the case management plan.
Create care plans including problems, goals and interventions designed to meet patient’s needs.
Implement and monitor the care plan to ensure the effectiveness and appropriateness of services
Evaluate patient’s progress toward goal achievement, including identification and evaluation of barriers to meeting or adhering to their medical plan of care, and systematically reassess for changes in goals and/or health status.
Intensive disease state education, direction, and support in achieving member self-care competence.
Utilize motivational interviewing skills to build patient engagement in care management plan of care.
Provide education, information, direction and support related to care plan goals.
Perform care management following the nursing process and standards of practice established by the Case Management Society of America (CMSA).
Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan.
Collaborate with the Social Worker by referring patients for SDOH needs and community resources and monitoring outcomes to ensure that services are being delivered, and patient needs are being met. Engage in professional development activities to keep abreast of care management practices and patient engagement strategies.
Establish a trusting relationship with patients, their families, and/or caregivers.
Collaborate with clinical staff and other care team patients to achieve patient goals.
Communicate telephonically with hospital case managers, physical therapists (PT), social workers, patients, and families/caregivers to facilitate a safe discharge plan.
Willingness to travel up to 10-20% locally to ArchWell Health centers to enhance collaboration with PCP and other members of the care team and/or engage with members face-to-face.
Required Skills/Abilities:
Subject matter expert in chronic medical conditions such as Chronic Lung Disease, Heart Failure, Diabetes, and Chronic/End Stage Kidney Disease.
Ability to plan, implement and evaluate patient specific care plans.
Experience with monitoring, assessing, recording, and adjusting plan accordingly.
Excellent verbal and written communication (including documentation) skills.
Excellent relationship management with patients, families, and care providers.
Strong organizational skills.
Strong interpersonal communication skills with exceptional active listening abilities.
Highly empathetic, non-judgmental, and open-minded.
Experience in a collaborative team environment.
Self-starter, critical thinker, and owner.
Demonstrated ability to work independently in a remote setting.
Working knowledge of patient medical records.
Working knowledge of community-based organizations and social services support agencies/network.
Minimum Qualifications:
Associate degree in Nursing required.
Bachelor’s Degree in Nursing (BSN) or RN with bachelor’s degree in a related clinical field preferred.
A valid, active, unrestricted Registered Nurse (RN) license in State of employment required.
Willingness to obtain an RN license in other states with an ArchWell Health center (compact and non-compact locations).
A minimum of 2 years’ clinical work experience required.
A minimum of 2 years’ case management experience in acute case management or ambulatory case management experience required.
A minimum of 1 year experience in disease management required.
Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) or willingness to obtain certification within a specified time.
ICD-10, CPT codes, HCPCS knowledge preferred.
Managed care experience including knowledge of HEDIS and CMS guidelines preferred.
Mission driven and motivated to join an organization that will transform the way we deliver accessible, clinically excellent care to seniors.
Proficient computer skills including Microsoft Office.
Embodies and serves as a role model of ArchWell Health’s Values:
Be compassionate
Strive for excellence
Earn trust
Show respect
Stat resilient
Always do the right thing
About ArchWell Health:
At ArchWell Health, we’re creating a community of caring designed to help our members stay healthy and engaged. By focusing on a strong provider-patient relationship, routine wellness, and staying active, our members enjoy a higher level of care and better quality of life after the age of 60. Everything we do is for seniors. We believe seniors should be heard, listened to, and given ample time by their physicians to live well later in life.
Our value-based care model is designed to prevent illnesses while keeping members healthy and happy in every aspect of their life. We deliver best-in-class primary care at comfortable, accessible neighborhood centers where older adults can feel at home and become part of a vibrant, wellness-focused community. We’re passionate about caring for older adults and united by the belief that caring has the power to change everything for our members.
ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.