RN Care Manager at Community Health Center of Fort Dodge, Inc – Eagle Grove, Iowa

RN CASE MANAGER (TCM/CCM)

Job Overview:

The RN Case Manager is responsible for coordinating patient care across transitions and ongoing chronic disease management. This role supports both Transitional Care Management (TCM) and Chronic Care Management (CCM) programs to improve patient outcomes, reduce hospital readmissions, and enhance continuity of care.

The RN Case Manager works collaboratively with providers, care teams, and community partners to ensure patients receive timely follow-up, education, and support. This position plays a critical role in advancing patient-centered care, improving access, and supporting population health initiatives across the organization.

Key Responsibilities:

Transitional Care Management (TCM)

• Identify eligible patients through hospital discharge reports, ED notifications, and internal referrals
• Complete patient outreach within 48 business hours of discharge
• Perform comprehensive transition assessments, including:
  • Medication reconciliation
  • Review of discharge instructions
  • Identification of barriers (transportation, SDOH, access)
• Coordinate and schedule follow-up visits within required TCM timeframes (7–14 days)
• Provide patient and caregiver education to support recovery and prevent readmissions
• Maintain communication with providers regarding patient status

Chronic Care Management (CCM)

• Identify and enroll eligible patients with multiple chronic conditions
• Develop, implement, and update individualized care plans
• Provide ongoing monthly patient outreach and care coordination
• Monitor chronic conditions and support patient self-management
• Coordinate services across providers, specialists, behavioral health, and community resources
• Track and document time spent on CCM services to support billing requirements

Care Coordination

• Serve as a primary point of contact for patients across episodes of care
• Facilitate communication between interdisciplinary team members
• Ensure completion of referrals, labs, diagnostics, and follow-up care
• Address care gaps and support preventative care initiatives

Documentation & Compliance

• Document all patient interactions in the EHR in accordance with TCM and CCM billing requirements
• Ensure compliance with CPT codes (e.g., 99495, 99496, 99490, 99439)
• Maintain accurate, timely, and audit-ready documentation
• Adhere to HRSA, CMS, and organizational policies

Quality & Performance Improvement

• Monitor outcomes including:
  • Readmissions
  • Follow-up compliance
  • Chronic disease management indicators
• Participate in quality improvement (QI) initiatives
• Assist in workflow optimization and program development

Patient Advocacy & Engagement

• Build strong relationships with patients and caregivers
• Identify and address social determinants of health (SDOH)
• Support patient engagement and adherence to care plans

Qualifications:

Education & Licensure

Experience:

• Minimum 2–3 years of clinical nursing experience required
• Experience in case management, care coordination, or population health preferred
• FQHC or outpatient experience preferred

Work Environment:

Knowledge, Skills, and Abilities

• Strong understanding of TCM and CCM program requirements and workflows
• Knowledge of chronic disease management and care coordination principles
• Ability to develop and manage care plans
• Strong communication and interpersonal skills
• Proficiency in EHR systems (Epic preferred)
• Ability to work collaboratively in a team-based care environment
• Strong organizational and time management skills

PHYSICAL DEMANDS AND WORK ENVIRONMENT

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 Physical demands: While performing the duties of this job, the employee is required to stand, walk, sit, use hands to finger, handle or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell; manage stress as it relates to essential job functions. The employee must have the ability to transfer or lift patients to exam table from chair or floor. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Work environment: While performing the duties of this job, the noise level in the work environment is usually minimal to moderate. The employee is subject to health hazards (contagious diseases, blood borne pathogens, etc.).