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Anchor Pediatrics - Lincoln

Nursing Care Manager - Pediatrics Full TIme (40 hours)


Under general supervision of medical home physician champion, and working within primary care practice setting, provides comprehensive care coordination services to patients with high risk or complex medical and/or behavioral health needs. Provides screenings, assessment, care coordination services, disease education and self-management support to patients and families.  Participates as a member of multidisciplinary healthcare team within the Patient-Centered Medical Home environment for patient-centered care. Works collaboratively with medical and behavioral health providers, other clinical, support and managerial staff to achieve desired quality and cost outcomes. Serves as medical home advocate and mentor to ensure effective and supportive patient/family-centered environment. Participates in efforts required to maintain NCQA (National Committee for Quality Assurance) Medical Home recognition.


As a member of the physician office practice, utilizes multidisciplinary team approach to identify opportunities to plan and coordinate care. Establishes relationships with children, youth and families through introductory visits dedicated to setting expectations for care coordination.

Promotes communication with families and among professional partners and defines minimal intervals between communications.

Provides condition specific and related medical, behavioral health, financial, educational, and social supportive resource information, while coaching patients and families to develop and maintain self-management skills.

Completes a child/youth and family assessment that includes family status, home environment growth and development assessment.

Working with the patient and family (as appropriate), establishes written care management plans, interventions, treatment, and self-management goals, and as appropriate, an emergency plan that reflects mutual goals.  Promotes compliance with and evaluates effectiveness of established care plan.

Utilizing established practice staff & system resources, ensures the coordination of all medical, developmental, behavioral health and social referrals and tracking of referrals, testing and other order results. Coordinates care with and referral to state-designated community health teams as appropriate.

Ensures health care team integrates multiple sources of health care information; communicates this summary to the patient/caregiver, thereby building caregiver skills and fostering relationships between the health care team and families.

Coordinates family-centered team meetings (across organizations as needed).

Supports and facilitates all transitions of care between practices and/or facilities and from pediatric to adult systems of care.  Functions as Patient-Centered Medical Home liaison to hospitals, long-term care institutions, specialists, and home health representatives to coordinate administrative and clinical issues related to patient care.  Interacts and coordinates activities with third party insurance case and disease management representatives regarding patient care issues within the Patient-Centered Medical Home.

Maximizes usage of electronic medical record/chronic disease and behavioral health registry reporting to effectively deliver and continually monitor care coordination and effectiveness of service delivery.

Initiates and maintains effective relationships within community as required by patient population.  Demonstrates flexibility and creativity in recommending resources to meet patient/family needs, such as identifying and utilizing appropriate cultural and community resources to support needs of diverse patient population.

Prepares and maintains quarterly reports on service volume, distribution of patients by plan and types of services provided.

Ensures open communication regarding patient status with providers and office staff.

Provides orientation, training, and consultation to other practice staff (including physicians and non-professional staff) regarding Patient-Centered Medical Home and Integrated Behavioral Health objectives.

Participates in quality improvement and evaluation processes related to Care Management.

Provides clinical triage of patient/family calls to the practice within established protocols, documents advice provided and sends to provider for review.

Manages requests for prescription refills, approves refills as provider delegate according to established protocols. Manages prior authorization process required by insurers.

May perform procedures or tests such as, but not limited to: Intramuscular injections, administration of immunizations, wound care/dressing.

Qualifications & Experience

Current licensure to practice as Registered Nurse in Rhode Island, or in another state that participates in Nurse Licensure Compact.

Demonstrated knowledge & skills necessary to provide care to patients with consideration of aging processes, human development stages & cultural patterns in each step of the care process.

At least three years professional nursing experience in community health setting, public health, or community nursing, including experience with chronic disease and/or behavioral health management.  Experience should demonstrate thorough knowledge of chronic disease and/or behavioral health management, with demonstrated effectiveness in coordinating patient care with primary care and/or behavioral health providers.  Case management experience with patient care coordination and disease management/education preferred. Experience utilizing EHR/disease registry reporting to prioritize patient outreach and follow up preferred. Experience in pediatrics or family care setting strongly preferred.  

Interested applicants should submit their resume and apply for Job ID: 19776 at   

Rhode Island Free Clinic

Patient Navigator/Community Health Worker 


Patient Navigator/Community Health Worker (40 hours): The full-time Bilingual Patient Navigator/Community health Worker will work as a strategic partner with Clinic staff and volunteers to further our model of high-quality, community-based healthcare services for uninsured adults. Reporting to the Clinic Practice Manager, they will work with RI Department of Health Programs including Wise Women Program and Women’s Cancer & Colorectal Screening Programs, as well as other Clinic interventions and programs, community resources, and Electronic Medical Records. 


Clinical Duties:

  • Serve as program liaison between the Clinic and RI Department of Health.
  • Identify and enroll Patients in the Wisewoman Program and Women’s Canner Screening Program, and additional programs including smoking cessation and others.  
  • Assist patients to overcome barriers and support adherence to program activities.
  • Provide exceptional navigation to connect patients with resources, and remove barriers to health care in general.
  • Support medical providers by providing tools and resources to help patients, including regular monitoring of health indicators including blood pressure at home.
  • Take patient vital signs, height and weight; record information in Electronic Medical Record and prepare patients for examinations.
  • Perform EKGs and waived testing (Glucometer, Urine Dips).
  • Coordinate access to community-based activity such as YMCA memberships.
  • Perform tracking, follow up, and data collection/maintenance to monitor client progress, and support grant reporting.

Administrative duties:

  • Work with clinic nurse and staff to ensure efficient patient flow during clinic sessions.
  • Greet patients, volunteers and Clinic guests.
  • Maintain timely and accurate records and documentation of specific deliverables for care.
  • Outreach to patients in a timely manner aligned with Clinic priorities & program guidelines.
  • Provide assistance to develop and generate reports from Electronic Medical Record.
  • Assist staff with data collection for grants and reporting.

Other Duties:

  • Bilingual staff will work with Clinic & Wellness Nurses and other providers to provide interpreter services as necessary.
  • Facilitates referrals to outside sources, tracks referrals & informs patient of upcoming appointments by phone & by mail.
  • Other duties as assigned.


  • Bilingual in Spanish and English required.
  • Bachelor’s Degree or equivalent experience
  • Critical thinking skills, initiative, reliability, follow-through, flexibility, and responsibility are required.
  • Excellent interpersonal and organizational skills.
  • Related work experience preferred.
  • Knowledge of HIPAA and OSHA requirements.
  • Knowledge of medical terminology.
  • Commitment to the Clinic’s mission and volunteer model of Medical Home care.

Physical Requirements

  • Must be able to lift 30 lbs.
  • Must be able to stoop, bend and turn without difficulty.
  • Meet with patients in the community; at their home or other community setting.
  • Ability to work evenings and weekends as required.


Rhode Island Free Clinic ( provides free comprehensive primary health care to uninsured, working poor, and low-income adults; and, serves as an educational site for trainees in health care fields. Care is provided through a dynamic statewide network of volunteer medical professionals working with academic, medical, and community partners, leveraging robust health care resources with a vitality that is unmatched in Rhode Island and remarkable in the nation. In 2020, the Clinic mobilized nearly 600 volunteers and community partners to provide over 13,000 patient visits to underserved adults, and over 5,700 hours of training for students in health care fields.   

TO APPLY:  Please email RESUME and COVER LETTER to:

No calls please.

Rhode Island Primary Care Physicians Corporation

Nurse Care Manager


The Nurse Care Manager will have the opportunity to work on a multidisciplinary healthcare team in a primary care setting. The Nurse Care Manager is responsible for providing comprehensive screenings, assessment, care coordination services, disease education, and self-management support to patients with targeted chronic health conditions. The Nurse Care Manager will be integrated into the office-based healthcare team to promote patient-centered care, frequent contact with primary care providers and medical home team members, and actively participate in multidisciplinary patient-centered care, frequent contact with primary care providers and medical home team members, and actively participate in multidisciplinary patient-centered team meetings.


  • Leverage EMR / chronic disease registry reporting to prioritize patient outreach and follow-up.
  • Complete initial patient assessment, including a comprehensive medical, psychosocial, and functional assessment of the patients.
  • Provide detailed education about patient’s specific chronic illness, including the pathology, signs and symptoms, complications, and medications used in treatment.
  • Assure that screening tests and immunizations are up to date.
  • Utilize a multidisciplinary team approach to address opportunities to plan and coordinate care.
  • Establish care management plans, interventions, treatment goals – including self-management goals, and contact schedules.
  • Promote compliance with care plan.
  • Coordinate care and communicate with multiple providers.
  • Review test results and track outcomes.
  • Review patient compliance issues.
  • Work one-on-one with patients.
  • Arrange group visits when necessary.
  • Identify and utilize cultural and community resources.
  • Ensure open communication with appropriate office staff.


  • Perform quality work within deadlines with or without direct supervision.
  • Share best practices among all teams, serve as a medical home advocate, mentor and lead by example to support a positive work environment, and encourage other staff to do the same.
  • Represent the practice in a positive manner to all patients and all applicable external clients.
  • Bring issues to the appropriate manager(s) in a timely manner for resolution.
  • Perform other related duties as assigned.



  • Licensed RN, State of Rhode Island.
  • 3-5 years of experience in community health setting, public health, chronic disease management, community nursing; case management preferred.
  • Certified as a diabetic educator or in another chronic care area, within 12 months of employment.
  • Experience working with primary care providers to coordinate care and disease management.
  • Experience working with patients regarding care coordination and disease management / education is preferred.
  • Bilingual- Spanish Speaking


  • Ability to work independently and collaboratively to achieve goals.
  • Highly organized and detailed.
  • Exercise sound judgment and decision making.
  • Ability to assess and differentiate priorities.
  • Excellent interpersonal skills.
  • Excellent written and verbal communication skills.
  • Ability to maintain confidentiality in accordance with HIPAA.
  • Proficiency with computer skills (i.e., Microsoft Word, Excel and Access, and Web-based applications).
  • Maintain current licenses and certificates.
  • Continue progressive professional development.

Job Type: Full-time

Please send Resume to:

Darlene Dorocz, ADN, RN, CDOE

Director of Nursing

Rhode Island Primary Care Physicians Corporation

Phone (401)654-4000 x103

Fax: (401) 654-4001


Our Mission

The mission of the Care Transformation Collaborative is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations we serve.