St. Mary's Good Samaritan PCHH Care Manager- RN in St. Louis, Missouri


Nurse Care Manager for Primary Care Health Home Initiative

Job Summary: Provides services necessary to implement individual treatment plans, reduce hospital inpatient admissions and interrupt patterns of frequent hospital emergency department use. Grant funded program to coordinate care and manage care for high risk patients to avoid re-admission.

Duties and Responsibilities:

  • **Identify appropriate high risk patients and use patient information to determine the level of participation in clinical care management services.

  • Assessment of preliminary service needs.

  • Develop care plans for each patient, including patient goals, preferences and optimal clinical outcomes.

  • Provide intensive monitoring follow-up and clinical management of high risk patients.

  • Monitoring of individual and population health status and service use to determine adherence to or variance from treatment guidelines.

  • Develop treatment guidelines for health teams to follow across risk levels or health conditions.

  • Develop and disseminate reports that indicate progress toward meeting desired outcomes for client satisfaction, health status, service delivery and costs.

  • Clinical care management activities generally include frequent patient contact, clinical assessment, medication review and reconciliation, communication with treating clinicians and medication adjustment by protocol.

  • Address medication alerts, hospital admissions/discharges and ER visits; including medication reconciliation.

  • Provide transitional care planning for Health Home participants (includes inpatient discharge planning, such that effective patient-centered, quality driven provider coordination is ensured. It also includes follow-up with patients who have been hospitalized or seen in the Emergency department within 72 hours of discharge).



  • RN license or eligible for licensure in the state of MO required.

  • 3 years of clinical nursing, case management and/or managing Medicaid patients Knowledge of basic concepts and principles of managed care

Preferred Qualifications:

  • Bachelor’s degree in health care preferred.

  • Case Management or similar certification

Organization: SSM Health Medical Group Business Office

Primary Location: Missouri-St. Louis-SSM Health St. Mary’s Hospital – St. Louis

Work Locations: SSM Health St. Mary’s Hospital – St. Louis (0100) 6420 Clayton Road St. Louis, 63117

Job: Nursing

Req ID: 18016270