ABOUT THE ROLE  

The Care Manager Registered Nurse (CMRN) is a hybrid role responsible for managing a panel of higher-acuity patients (HPP) through a combination of primarily remote case management and targeted in-clinic support, such as High-Risk Huddle meetings.  

This role is accountable for end-to-end care management, with a strong focus on: 

• Reducing avoidable admissions (ADK) and emergency department utilization (EDK)  
• Improving clinical outcomes and patient experience  
• Supporting care continuity across the healthcare continuum  

The CMRN partners closely with providers, clinic staff, and Care Center Managers (CCMs) to deliver coordinated, proactive, and patient-centered care.  This position is primarily remote, with regular in-office presence based on patient or program needs. 

Specific responsibilities for this role will include, but are not limited to: 

Panel Management & Care Coordination (Primarily – Remote) 

• Manage a defined panel of high-risk patients, delivering comprehensive, longitudinal case management  
• Develop, implement, and continuously update individualized care plans in collaboration with providers and care teams  
• Perform ongoing telephonic outreach and monitoring to improve patient outcomes 
• Coordinate care across the patients HPC provider, specialists, hospitals, EDs, SNFs, and community resources  
• Partner and collaborate with transitions of care team, for a smooth transition and to ensure that the patient needs are met following the transitions of care period 

Clinical Collaboration & Outcomes Management 

• Partner with providers, MAs, LPNs, and Care Center Managers to align on patient care plans and priorities  
• Escalate clinical concerns and barriers to care in real time  
• Participate in team huddles, case reviews, and interdisciplinary care discussions  
• Track and improve quality and utilization metrics tied to patient outcomes  

In-Clinic Responsibilities (Hybrid Component) 

• Maintain in-office presence minimum of 1 time a month and as needed to:  
  • Support high-risk patient visits  
  • Assist with care coordination for complex patients  

Home & Community-Based Support  

• Coordinate with in office LPN for occasional home visits for high-risk or complex patients when clinically appropriate 
• Assess social determinants of health, home safety, and barriers to care  
• Coordinate community-based services and resources to support patient care plan goals 

Patient & Family Engagement 

• Build trusted relationships with patients, families, and caregivers  
• Provide education on disease management, medications, and care plans  
• Utilize motivational interviewing and coaching techniques to drive behavior change  

Program Quality, Compliance & Best Practices 

• Adhere to care management protocols, regulatory requirements, and documentation standards  
• Support continuous improvement of care management workflows and outcomes  
• Identify and report gaps, risks, or adverse events  
• Contribute to development of best practices, training, and process improvements 

ABOUT YOU 

You would be a great fit for this position if you have a minimum of 2 years of experience as a care manager embedded into an interdisciplinary team and the following: 

• Active registered nurse (RN) license in North Carolina  
• BLS certification  
• Experience working in a primary care clinic focused on chronic disease management 
• Experience with behavioral health and community-based organizations preferred  
• Experience with motivational interviewing, behavior change, health promotion, and coaching  
• Strong verbal and written communication skills and customer service orientation  

From a cultural perspective, you are: 

• Patient-first, team-oriented  
• Agile and thoughtful in a fast-paced environment  
• Solutions-driven, always looking to improve  
• Accountable, with high standards for yourself and others  
• Hands-on and collaborative across diverse teams  
• Clear, concise communicator who follows through  
• Positive, assuming good intent  
• Customer-focused, with a passion for serving patients and providers 

ABOUT HOPSCOTCH PRIMARY CARE 

At Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities.  Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities.  We are on a mission to transform healthcare in rural America.  We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most.    

Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch.  Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible.  Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time.  

Today, we are serving thousands of patients in our value-based care model and the number is growing every day.  If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we’d like to meet you. 

ABOUT THE ROLE  

As a Licensed Practical Nurse (LPN), you will perform an important function of the organization and care delivery model. High levels of flexibility, commitment, attention to detail, and problem-solving are required to be successful. You will be expected to build relationships with Hopscotch care team members and patients. LPNs will work closely and collaboratively with their teammates to greet and room Hopscotch patients. LPNs will be expected to assist in assessing patients’ health conditions, including performing routine diagnostic testing during appointments. This role is based primarily in clinic during business hours.  The location for this position is in our clinic in Burnsville, NC.  This person will be working 4 days a week (approximately 30 hours/week).

Compensation range for this full-time position is between $30 - $34 per hour depending on clinic location and candidate experience/qualifications. 

WHAT YOU’LL DO 

Specific responsibilities for this role will include, but are not limited to:  

• Provides direct patient care under the supervision of a RN, APP, and/or physician, evaluates outcomes, consults with other health team members as required and adjusts nursing care processes as indicated to ensure optimal patient care.  
• Delivers an exceptional patient experience, and helps patients prepare for their provider visit    
• Maintains current knowledge of medications and their correct administration based on age of the patient and his/her clinical condition.  
• Delivers patient screenings per protocols    
• Follows the medication rights and reduces the potential for medication errors  
• Conducts routine quality control checks, including infection control measures, equipment QAs, and checks for expired medication and supplies    
• Ensures exam rooms are stocked, clean, safe, and ready for patient visits   
• Provides telephone triage per approved triage protocols and follows escalation pathways  
• Under direction of a Provider, offer LPN appropriate “visits”, including but not limited to: administering vaccinations, performing procedures, ABI, spirometry, EKGs, etc. (depending on local laws and regulations)   
• Performs waived laboratory testing   
• Schedules diagnostic testing and prior authorization  
• Administers Social Determinants of Health Screenings and addresses identified needs.  
• Develop trusted relationships with patients by providing support and advocacy to help achieve health goals      
• Help patients access resources in the community to address social and economic needs    
• Identify high priority needs to ensure patient satisfaction and positive outcomes, and work with the care team to develop plans and take action to address those needs    
• Facilitate communication across all parties (Patient, Hopscotch team, community providers, family, etc)    
• Applies or assists with the application of durable medical equipment   
• Participates in care team meetings to discuss patient care and clinic operations    
• Under the direction and supervision of a Registered Nurse, the LPN will participate in the nursing process related to assessing, planning, and implementation of nursing activities    
• Supporting patients in the community through home visits 
• Other duties, as assigned   
• All LPN duties will follow the LPN scope of practice in which the LPN provides patient care  

ABOUT YOU 

We’re looking for motivated Licensed Practical Nurse with: 

• A minimum 2 years of experience as a LPN, primary care experience strongly preferred  
• Active LPN Licensure in North Carolina 
• BLS Certification required 
• EMR experience and proficiency required, athenahealth experience preferred 
• Strong communication skills and customer service orientation  
• Demonstrated problem-solving skills, accountability, and a flexible, positive attitude  
• US work authorization  

Driving and Motor Vehicle Compliance
Driving is an essential function of this role. Employees in this position are required to operate a personal or company vehicle for business purposes. As a condition of employment, candidates must:

• Possess and maintain a valid, unrestricted driver’s license
• Provide and maintain current documentation of vehicle registration and proof of insurance
• Maintain a driving record that meets company standards
• Consent to and successfully pass a Motor Vehicle Record (MVR) check prior to employment and at intervals determined by the company

From a cultural perspective, you are: 

• Agile, yet thoughtful and can work effectively in a fast-paced, ever-changing environment 
• Constantly seeking ways to simplify and improve how things are done, bringing a positive attitude to challenges 
• Accountable, holding yourself and others to a high standard and seek to support and develop others 
• Willing to roll up your sleeves to support the work required and collaborate effectively with people of all backgrounds 
• Concise and articulate, drive towards clarity and deliver on your commitments 
• Collaborative, assuming positive intentions 
• Customer-focused, with a passion for serving patients and providers who make healthcare possible 

You will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status 

ABOUT HOPSCOTCH PRIMARY CARE 

At Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities.  Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities.  We are on a mission to transform healthcare in rural America.  We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most.    

Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch.  Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible.  Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time.  

Today, we are serving thousands of patients in our value-based care model and the number is growing every day.  If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we’d like to meet you. 

ABOUT THE ROLE  

Hopscotch Primary Care is seeking a clinically sound, mission-driven Licensed Clinical Social Worker to support the behavioral health needs of our patients. This role will be a key resource for primary care teams across the Western North Carolina region. As Hopscotch continues to grow and serve patients with increasingly complex behavioral health needs, this role will play a critical part in expanding access to high-quality, integrated behavioral health care across our clinics.   

This role will work closely with primary care providers and care teams to deliver coordinated, patient-centered behavioral health care. They are responsible for assessing the behavioral health needs of patients, making referrals to appropriate behavioral health resources and specialists and providing counseling and other treatments as necessary.

This role offers flexibility in care delivery, including a mix of in-person and telehealth visits, and will involve travel to clinic locations across Western North Carolina.

WHAT YOU’LL DO 

Specific responsibilities for this role will include, but are not limited to:  

• Collaborate with primary care providers and care team members to identify and engage patients into the Behavioral Health Program
• Screen and assess patients using evidence-based tools (e.g., PHQ-9, GAD-7) for common mental health and substance use disorders
• Provide counseling via in-person and telehealth visits, with visit frequency and duration guided by patient need and clinical judgment
• Develop, implement, and monitor individualized behavioral health care plans
• Provide crisis assessment and escalation support when needed
• Coordinate care with external psychiatric providers and specialty behavioral health resources, including building relationships to strengthen Hopscotch’s behavioral health network across the region
• Serve as a behavioral health resource to clinic teams, supporting real-time consultation and care planning
• Contribute to the ongoing development and refinement of Hopscotch’s Behavioral Health Program
• Participate in clinical team meetings to align on patient care plans
• Accurate and timely documentation of patient encounters and care coordination activities

ABOUT YOU 

You would be a great fit for this role if you:

• Hold active LCSW, LCMHC, or LCMHCS in the state of North Carolina
• Have 3+ years of experience providing behavioral health services in a medical, integrated care, or crisis-focused setting
• Experience utilizing electronic medical record systems; specific experience with Athena is a plus, but not required
• Are clinically confident with patient assessment, safety planning, and mobilizing emergency resources
• Are comfortable managing patients with complex behavioral health needs, including serious mental illness, substance use disorders, and social complexity
• Have a strong understanding of the behavioral health and crisis resources available in Western North Carolina (or are eager to learn)
• Communicate clearly and effectively with providers, care teams, and external partners
• Thrive in a fast-paced, evolving environment and are comfortable helping build structure where needed
• Are willing and able to travel to clinic locations in Western North Carolina

From a Cultural Perspective, You Are

• Patient-centered, compassionate, and mission-driven
• Accountable, holding yourself and others to high clinical standards
• Collaborative, assuming positive intent and working effectively across disciplines
• Adaptable and solution-oriented, bringing ideas to improve behavioral health care delivery
• Willing to roll up your sleeves to support patients and care teams in rural communities

About the Role

We are looking for a resident or medical school student to join us for a short-term internship opportunity! Join a fast-paced, mission-driven value-based care start-up and help shape the future of primary care in small towns and rural communities

What You’ll Do

Specific responsibilities for this role will include, but are not limited to:

• Get a crash course in healthcare entrepreneurship and make real contributions while doing it 
• Work directly with the Chief Medical Officer, VP of Care Delivery & Innovation, and other clinicians on shaping the clinical care model. Example clinical areas for short-term projects include preventive health screenings, end-of-life care, dementia, and complex chronic disease management. Scope of projects may include:
  • Mapping clinical workflows
  • Reviewing and synthesizing literature to inform care pathways
  • Building first drafts of clinical guidelines and protocols

About You

You would be a great fit for this position if you are:

• 3^rd or 4^th year medical student at an LCME or COCA accredited medical school, OR
• Intern, resident, or fellow at and ACGME accredited training program with training in adult primary care, including internal medicine, family medicine, and/or geriatric medicine
• Organized, proactive, and collaborative
• Interested in healthcare innovation, startups, or value-based care
• Able to give thoughtful clinical input and open to rapid iteratio