Population Health Nurse Care Manager

Working title: Population Health Nurse Care Manager                      

Position #:  1              

Classification title: Registered Nurse               

Division: Community Health Center

Program: Care Management Services                                                            

Reports to: Population Health Program Manager   

FLSA status: Non-Exempt; 32 hours a week 

Schedule: Monday-Friday; 9:00am to 4:30pm

Wage Range: $34.52-$50.04 hourly depending on number of years of transferrable experience and internal equity

RiverStone Health:

Serving the Yellowstone County community and south-central Montana for nearly 50 years, RiverStone Health is an essential provider of personal and public health services. Health, Education, Leadership and Protection – HELP is what we do.  From medical, dental and behavioral healthcare; home care and hospice; public health services like immunizations, WIC, health promotion and restaurant inspections; and educating the next generation of health professionals, our expertise spans all ages and stages of life. Underlying principles of access, affordability, compassion and quality in all interactions, RiverStone Health improves life, health and safety for all of the communities we serve.

Division and Program Overview: 

Coordinates, monitors, and works closely in conjunction with the Patient Care Team in a Patient Centered Medical Home model, to ensure effective quality and coordination of services. Managing patient care is a team effort that involves clinical and nonclinical staff (e.g., physicians, nurse practitioners, physician assistants, nurses, medical assistants, educators, front desk staff, schedulers, etc.) interacting with patients to achieve stated objectives. The position interacts with community care partners to assure smooth transitions of care between agencies.

Job Summary:

The Population Health Nurse Care Manager provides proactive, longitudinal nursing care management for patients with complex chronic conditions, elevated health risks, and barriers to accessing care. Working collaboratively with patients, families, primary care providers, and the interdisciplinary care team, the RN assesses needs, develops individualized care plans, supports chronic disease self-management, coordinates services, and monitors progress toward patient-centered goals. The position uses clinical information, risk stratification, and population health data to prioritize outreach, close care gaps, and improve health outcomes. This role also supports RiverStone Health’s participation in other quality and value-based care initiatives.

Essential Functions/Major Duties and Responsibilities: Nursing Services 95%            

• Maintains an assigned caseload of high-risk patients, prioritizing services according to clinical acuity, utilization, barriers to care, and patient goals.
• Reviews referrals and population health reports to identify patients appropriate for care management; explains services and engages patients in ongoing participation.
• Performs and documents a comprehensive initial care plan assessment addressing physical and behavioral health, medication use, functional status, health literacy, social and financial needs, barriers to accessing care, patient strengths, and available caregiver support.
• Collaboratively develops and maintains an individualized, patient-centered care plan with the patient, caregivers as appropriate, primary care provider, and interdisciplinary care team. Establishes measurable goals, planned interventions, responsible team members, and follow-up intervals.
• Provides individualized patient and caregiver education and coaching on chronic conditions, prevention, medication adherence, symptom monitoring, healthy behaviors, and use of supplies and equipment. Uses patient-centered goal setting and self-management strategies to build confidence and capacity for self-care.
• Collaborates with the Transitions of Care team to identify patients needing ongoing care management following hospital or emergency department encounters. Provides continued assessment, medication reconciliation, self-management support, and coordination of follow-up services for assigned patients.
• Collaborates with panel managers, scheduling staff, and clinical teams to address care gaps requiring nursing assessment, patient education, or clinical coordination.
• Conducts occasional home visits, as appropriate, to assess patient needs, provide education and self-management support, and coordinate care for patients receiving care management services.
• Performs and documents ongoing reassessment at intervals based on patient needs and applicable program requirements. Monitors progress toward goals, updates the care plan, communicates concerns and recommended treatment changes to the treating provider, and implements orders and approved protocols within RN scope of practice.
• Completes accurate, timely documentation of care management activities, patient consent when required, and service time, and collaborates with billing staff to support appropriate coding and reimbursement under applicable payer requirements
• Implements evidence-based care, chronic disease protocols and guidelines. Utilizes registry to identify patients with chronic conditions, and gaps in clinical care. Ensures appropriate follow-up to address care gaps. Monitors individual patient progress and population health management.
• Assists with Value-Based Care and population Health initiatives. Participates in the Health Center’s quality improvement activities to enhance care management in the office setting.
• Coordinates with other care managers and disciplines to clarify responsibilities, facilitate warm handoffs, and maintain a coordinated patient care plan.
• Identifies education/training opportunities in support of health improvement initiatives. Acts as a resource for clinic staff for problem solving. Disseminates educational materials and other resources.
• Participates in developing, implementing, and evaluating care management workflows.
• Tracks progress toward patient goals and relevant population health outcomes and participates in improvement activities when expected results are not achieved.

Non-Essential Functions                                                                                      5%

• Perform other duties as assigned in support of the organization’s mission and goals.

Education and Experience:

Minimum Qualifications

• Graduation from an accredited registered nursing program
• Two years of clinical nursing experience, preferably involving chronic disease management, ambulatory care, care coordination, home health, or transitions of care.
• Excellent assessment and triage skills.
• Excellent communication and interpersonal skills.

Preferred Qualifications:

• BSN
• Care management, population health, FQHC practice, or work with patients experiencing complex medical and social needs.

Certificates, Licenses, Registrations:

• Current license as a Registered Nurse in the State of Montana in good standing
• Valid State of Montana Driver’s License.
• BLS Certification

Knowledge, Skills, and Abilities:

• Computer literacy, in Microsoft Office Suite, access and query electronic health records .
• Knowledge of current practices in population health
• Ability to identify disparities and develop programs/intervention to help reduce them
• Disease specific standards of care
• Care planning
• SMART goal setting
• Chronic disease self-management coaching technique
• Assessment techniques and practices for physical and mental health
• Understand and follow HIPAA regulations and practices
• Organize resources according to prescribed standards
• Establish priorities, prepare reports and make presentations according to prescribed standards
• Understand and follow verbal and/or written policies, procedures, and instructions
• Establish and maintain effective working relationships with patients, fellow employees, supervisors, community service organization representatives and citizens.
• Work in a team toward a common goal
• Work independently, be organized, and be a self-starter

Customer Service Excellence

• Doing things right the first time
• Making people feel welcome
• Showing respect for each customer
• Anticipating customer needs and concerns
• Keeping customers informed
• Helping and going the extra mile
• Responding quickly
• Protecting privacy and confidentiality
• Demonstrating proper telephone etiquette
• Taking responsibility for handling complaints
• Being professional
• Taking ownership of your attitude toward Service Excellence.

Supervision:

• None

Physical Demands and Working Conditions:

• Work is primarily performed in a clinical office setting, with occasional travel to patient homes and community settings. Sitting and standing regularly
• Occasional lifting up to 15 pounds
• Risk of needlestick injury is possible. 
• The position is regularly exposed to biological pathogens and contagious diseases where Personal Protective Equipment (PPE) and special precautions must be taken due to reduce exposure and mitigate risk.
• Create and maintain a safe/secure working environment by adhering to safety, security, and health requirements. Integrates injury, illness, and loss prevention into job activities by attending any necessary training and implementing best practices.
• Home visits may involve variable environmental conditions, including stairs, uneven walking surfaces, weather exposure, pets, smoke, and other potential hazards.

Freedom to Act & Decision Making:

• Works under the direction of the Population Health Program Manager 
• Work is structured by regulations and established nursing practices. 
• The position makes independent professional judgements regarding patient health. 
• Decisions directly affect the quality of services provided to the public.

Communications & Networking:

• Regular written and verbal communication with care team members, patients, family members and outside entities.
• Contacts are often non-routine and may require use of approaches that consider the needs, concerns or unique circumstances surrounding particular patients.
• Hostility, debate or conflict may be characteristic of some patient contacts.
• Communication with others is a critical element of the position because the purpose of the contact may be to negotiate matters involving significant issues of importance.
• Work directly with other care team members to provide whole person care for patients. 
• Act as a resource for clerical staff to resolve matters concerning procedures, patients, and appointments.
• Communicate and coordinate with others to maximize the effectiveness and efficiency of interagency operations and activities.

Budget & Resource Management:

Responsible for efficient use of time, supplies, and resources to support cost-effective operations.