Job Description

Assist the patient-centered medical home inter-disciplinary team and patient with development of care plans, coordination of services and addressing social determinants/barriers to care. Follow-up with high-risk patient populations, including care transitions and those patients with multiple chronic conditions, to review care plans and goals, updating as outcomes are achieved or additional goals or barriers are identified. Works with the patients and families to access resources and adopt healthy lifestyles.


To perform this job successfully, an individual must be familiar with the principles of care management and preventive care guidelines. Must have the ability to prioritize a case load, combining comprehensive nursing knowledge and skills with cost savings methodology and techniques. Must have the ability to interact with provider teams, healthcare professionals, and patients/caregivers/family in a professional manner. Knowledge of physical and behavioral health medications. Perform each essential duty listed above satisfactorily and with professionalism and courtesy to others, able to organize effectively and efficiently, and carry out workload. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Bilingual in English/Spanish preferred.


  • Must be able to obtain a fingerprint clearance If not already obtained, Fingerprint Clearance card application must be submitted within five (5) business days of employment.
  • Must be able to successfully pass a background check, a health fitness to duty and drug screen.
  • Degree or Diploma as Registered Nurse or Licensed Practical Nurse from an accredited School of Nursing.
  • At least one (1) year related care management experience in a primary care ambulatory setting or equivalent nursing setting preferred.
  • Experience in community liaison with Support Agencies and Non-Profits
  • Knowledge of computer and general office machines.
  • Accurate typing and orderly record keeping.
  • Current Arizona State Board of Nursing License.
  • Care Management certification preferred.