**Description** **Our team is growing! Pardee BlueMD, a part of the Pardee UNC Health Care organization, is a primary care physician practice network organized as a Federally Qualified Health Center (FQHC). Our full-time positions offer a range of benefits, including medical, vision and dental insurance, retirement savings, paid time off, and more. Come be happy with Pardee!** Summary: The Ambulatory Care Manager (RN) is responsible for assessment of the patient’s needs for community care support systems and development of a patient-centered plan of care. The Care Manager will collaborate with patients, their families/caregivers, providers, and interdisciplinary care team for overall care coordination to develop the plan of care and initiate and monitor services. Responsibilities: • Assesses and evaluates medical, psychosocial and social needs of patients and their families. • Develops plan of care in collaboration with interdisciplinary care team, patients and their families/caregivers. • Develops a self-management plan in collaboration with patient and family/caregiver to assist with identification of risk and appropriate interventions. • Educates patients and their family/caregivers regarding disease processes, medication management, symptom exacerbation and appropriate site of care. • Monitors patient status and progress towards meeting care plan goals and adjusts the care plan accordingly. Identifies problems and needs of the assigned client, strengths and weaknesses, available resources, and financial status relative to care needs. • Assesses for Social Determinates of Health (SDOH) and any barriers to care and makes referrals to community resources as appropriate. Provides assistance with linkage to community resources to enhance client/family coping capacity. • Prioritizes caseload according to need and available resources. • Meets with patients face-to-face while in office for appointments or follow-up by phone. Travels between sites to meet with patients as necessary. **Other information:** Required • Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states by the day of clinical care. • Three (3) years of experience working in a clinical capacity in an acute care, home health, or long-term care setting. • One (1) year of experience working as a Registered Nurse (RN) **Job Details** Legal Employer: Pardee - HCHC Entity: Pardee UNC Health Care Organization Unit: Blue MD Administration Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Hybrid Work Schedule: Day Job Location of Job: DR PARK Exempt From Overtime: Exempt: No Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.