Patient Centered Health Home (PCHH) Nurse Care Manager
Company: Affinia Healthcare
Location: Saint Louis
Posted on: February 14, 2026
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Job Description:
Job Description Job Description POSITION SUMMARY: Perform the
duties required to coordinate and monitor provision of wellness and
prevention initiatives for patients enrolled in Primary Health
Homes. POSITION QUALIFICATION REQUIREMENTS Education: Registered
Nurse Diploma or Bachelor of Science in Nursing. Experience: Three
(3) years as an RN in community clinic, public health nursing,
and/or hospital setting; including dispensing sample drugs and
monitoring effects. Skills and Abilities (which may be
representative but not all inclusive of those commonly, associated
with this position): Good computer skills including the use of word
processing and e-mail software. Good oral and verbal communication
skills. Good organizational and self-motivation skills. Ability to
maintain confidentiality. Ability to motivate and educate clients
and staff. Transportation Requirement : Must possess a valid
driver's license and automobile with insurance coverage as required
by the State of Missouri. License(s)/Certificate(s): Licensed as RN
in the State of Missouri; CPR certification. FUNCTIONS OF THE JOB
Essential Functions Enrollment and management of required caseload.
Completing monthly touches per regulations/guidance. Assist in
developing treatment plan health care goals for individuals with
co-occurring chronic diseases. Develop wellness and prevention
initiatives. Facilitate health education groups. Keep patients'
records. Complete appropriate forms and reports. Provide
appropriate documentation. Adhere to patient confidentiality.
Participate in the initial treatment plan development for all
Primary care health home enrollees. Assist in contacting medical
providers and hospitals for admission/discharge. Provide training
on medical diseases, treatments, and medications. Initiate the
referral of high-risk patients and families for special services,
team management, and track the patient's referral (i.e.) abnormal
lab results. Collaborate with behavioral health and medical teams
to develop patient-centered plan of care. Track required
assessments and screenings. Assist with referrals to community and
social support services. Assist in implementing MHD health
technology programs and initiatives (i.e., Cyber Access, metabolic
screening). Monitor HIT tools and reports for treatment. Medical
alerts and hospital admissions/discharges. Monitor and report
performance measures and outcomes. Consult with Community Support
Staff regarding identified health conditions. Perform other duties
as assigned. Marginal Functions: Assist providers with enrolled
patients, take and record vital signs as necessary, review and
report abnormal results. Observe for abnormal signs and symptoms,
document, and report to provider. Assist with implementation of
Quality Improvement Programs. Attend mandatory meetings and
training courses. Submission of monthly reports as scheduled.
Supervises: None NOTE: SMOKING IS PROHIBITED IN THE WORK
ENVIRONMENT NOTE: ALL APPLICANTS MUST PROVIDE CONTACT INFORMATION
FOR THREE REFERENCES AN EQUAL OPPORTUNITY SERVICES PROVIDED ON A
NON-DISCRIMINATORY BASIS
Keywords: Affinia Healthcare, Chesterfield , Patient Centered Health Home (PCHH) Nurse Care Manager, Healthcare , Saint Louis, Missouri
