The posting
About Hopscotch Primary Care
At Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities. Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities. We are on a mission to transform healthcare in rural America. We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most.
Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch. Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time.
Today, we are serving thousands of patients in our value-based care model and the number is growing every day. If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we’d like to meet you.
ABOUT THE ROLE
The Care Manager Registered Nurse (CMRN) is a hybrid role responsible for managing a panel of higher-acuity patients (HPP) through a combination of primarily remote case management and targeted in-clinic support, such as High-Risk Huddle meetings.
This role is accountable for end-to-end care management, with a strong focus on:
- Reducing avoidable admissions (ADK) and emergency department utilization (EDK)
- Improving clinical outcomes and patient experience
- Supporting care continuity across the healthcare continuum
The CMRN partners closely with providers, clinic staff, and Care Center Managers (CCMs) to deliver coordinated, proactive, and patient-centered care. This position is primarily remote, with regular in-office presence based on patient or program needs.
Specific responsibilities for this role will include, but are not limited to:
Panel Management & Care Coordination (Primarily – Remote)
- Manage a defined panel of high-risk patients, delivering comprehensive, longitudinal case management
- Develop, implement, and continuously update individualized care plans in collaboration with providers and care teams
- Perform ongoing telephonic outreach and monitoring to improve patient outcomes
- Coordinate care across the patients HPC provider, specialists, hospitals, EDs, SNFs, and community resources
- Partner and collaborate with transitions of care team, for a smooth transition and to ensure that the patient needs are met following the transitions of care period
Clinical Collaboration & Outcomes Management
- Partner with providers, MAs, LPNs, and Care Center Managers to align on patient care plans and priorities
- Escalate clinical concerns and barriers to care in real time
- Participate in team huddles, case reviews, and interdisciplinary care discussions
- Track and improve quality and utilization metrics tied to patient outcomes
In-Clinic Responsibilities (Hybrid Component)
- Maintain in-office presence minimum of 1 time a month and as needed to: Support high-risk patient visits Assist with care coordination for complex patients
Home & Community-Based Support
- Coordinate with in office LPN for occasional home visits for high-risk or complex patients when clinically appropriate
- Assess social determinants of health, home safety, and barriers to care
- Coordinate community-based services and resources to support patient care plan goals
Patient & Family Engagement
- Build trusted relationships with patients, families, and caregivers
- Provide education on disease management, medications, and care plans
- Utilize motivational interviewing and coaching techniques to drive behavior change
Program Quality, Compliance & Best Practices
- Adhere to care management protocols, regulatory requirements, and documentation standards
- Support continuous improvement of care management workflows and outcomes
- Identify and report gaps, risks, or adverse events
- Contribute to development of best practices, training, and process improvements
ABOUT YOU
You would be a great fit for this position if you have a minimum of 2 years of experience as a care manager embedded into an interdisciplinary team and the following:
- Active registered nurse (RN) license in North Carolina
- BLS certification
- Experience working in a primary care clinic focused on chronic disease management
- Experience with behavioral health and community-based organizations preferred
- Experience with motivational interviewing, behavior change, health promotion, and coaching
- Strong verbal and written communication skills and customer service orientation
From a cultural perspective, you are:
- Patient-first, team-oriented
- Agile and thoughtful in a fast-paced environment
- Solutions-driven, always looking to improve
- Accountable, with high standards for yourself and others
- Hands-on and collaborative across diverse teams
- Clear, concise communicator who follows through
- Positive, assuming good intent
- Customer-focused, with a passion for serving patients and providers
At Hopscotch Primary Care, we embrace diversity, invest in a culture of inclusion and positivity and encourage all to apply to join our team. You will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
