Population Health Nurse Case Manager

Job Summary

The Population Health Nurse Case Manager is vital to ensuring safe, coordinated and effective transitions of care across settings from hospital to home and between care providers for CVCH patients, families and caregivers. The work entails integrating population health management strategies with case management to improve outcomes, reduce hospital readmissions and address social determinants of health. This role supports the mission of CVCH through collaboration with internal and external care teams to improve population health outcomes.

Primary responsibilities focus on transitional care planning for Medicare patients by arranging follow up appointments, home care, rehabilitation services and medication management. The nurse case manager helps identify the appropriate care setting and ensures continuity of care services in coordination with physicians, social workers, therapist and family members while ensuring transitions are safe, patient centered and aligned with improving quality and enhancing patient outcomes.

Essential Functions: These functions are fundamental to the role and must be performed with or without a reasonable accommodation.

• Develops, implements, and evaluates individualized, patient‑ and family‑centered plans of care, in collaboration with primary care providers, with emphasis on transitional care following inpatient hospitalizations or emergency department visits.
• Conducts comprehensive assessments of patients' physical, emotional, social, and environmental needs to establish baseline care requirements and identify barriers to care.
• Applies advanced clinical nursing expertise to support management of complex conditions, including assessment, symptom monitoring, patient education, and care coordination in collaboration with primary care providers and the interdisciplinary team care team.
• Provides care coordination and clinical support within the RN scope of practice, organizational policies, standing orders, and provider-directed plans of care.
• Communicates and coordinates effectively with interdisciplinary care teams to ensure accurate triage, shared understanding, and seamless management of patient needs across care transitions.
• Stratifies patient populations by risk level to prioritize interventions and optimize care delivery for patients with multiple chronic conditions.
• Collaborates with providers and care team to support appropriate frequency of provider visits and chronic care management encounters, based on patients' risk and clinical needs.
• Develops, maintains, and strengthens relationships with external partners and community organizations, including post‑acute care providers, behavioral health services, specialty providers, and community‑based resources, to support continuity of care and improved outcomes.
• Coordinates with external health and human service agencies to address social determinants of health, including transportation, food insecurity, utility assistance, and welfare checks.
• Leverages electronic health records, analytics, and telehealth technologies to document care, share care summaries, monitor patient progress, and support communication across the care continuum.
• Monitors and evaluates patient and program outcomes, including chronic disease control and reduction of hospital admissions and readmissions, and adjusts care strategies as indicated.

Essential Duties & Responsibilities: These functions are fundamental to the role and must be performed with or without a reasonable accommodation.

• Performs other duties and tasks as assigned by supervisor
• Start shift on time and meet attendance standards per the FTE assigned in HRIS system.
• Follow safety policies and maintain a clean, safe work environment.
• Demonstrate sound work ethics, flexibility, and cultural sensitivity
• Uphold CVCH's mission and core values in all interactions.
• Comply with CVCH policies, Joint Commission standards, and HIPPA regulations.

Non-Essential Functions: These are tasks that are included in the role but are not critical. They may be reassigned or modified without fundamentally changing the job.

• Participate in internal committees, department huddles, department meeting or special projects.

Qualifications:

Education

• Bachelor's degree in nursing required.

Certification/Licensure

• Current RN license for Washington State required.

Experience

• Minimum of three (3) years direct RN patient care required, provider practice or clinic health setting preferred:
• Experience with Care Coordination, Case Management, Home Health or Behavior Health preferred.
• Experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
• Experience with health IT systems and data reports preferred.

Language Skills

• English fluency required

Skills & Competencies needed:

• Strong interpersonal and communication skills
• Analytical and problem-solving abilities
• Ability to manage sensitive and confidential information
• Competence in basic computer skills
• Ability to work independently and to use critical thinking
• Ability to develop clinical judgement
• Ability to listen effectively and provide sensitive information

Work Environment & Physical Demands:

• Typical office environment
• Sit, stand, walk, often
• Reach occasionally
• Kneel or crouch minimally
• May need to lift up to 10 pounds
• Visual acuity for close and distance work

Exposure to Hazards:

• Moderate noise
• Standard working conditions

Blood/Fluid Exposure Risk:

• Category I - Tasks routinely involve a potential for mucous membrane or skin contact exposure to blood, fluids or tissue. Use of personal protective equipment (PPE), when appropriate, is required

Age Specific Competency

• Neonatal (Birth - 30 days)
• Infant (30 days to less than 1 year)
• Pediatric (1 year - 12 years)
• Adolescent (12 years - 18 years)
• Adult (18 years - 65 years)
• Geriatric (65 years - Death)

Telecommuting:

• Eligible for Telecommuting.

Equal Opportunity Statement:

• CVCH is an equal opportunity employer and embraces diversity in the workplace. We are committed to providing a respectful, inclusive, and supportive environment for all employees.

Benefits

• Coverage below based on a 1.0 FTE; Medical, Dental, Paid Leave, Holidays are prorated based on FTE

Benefit:

Coverage:

Effective:

Medical

Premera (Self Insured)

Preferred Provider

Employee covered - $70.00 per month

Dependents covered - please refer to the benefits Guide 2026 for rates

First of the month following the first date of employment.

Dental

Washington Dental

Employee covered - 100%

Dependents covered - 50%

First of the month following the first date of employment.

Paid Leave

120 hours - Year 1

136 hours - Year 2

Each year after that employee will accrue 8 hours of PTO each year, on their anniversary date, until they reach a maximum of 208 hours at 10+ years.

Paid Leave may be used immediately for sick leave and after 3 months employment for vacation. Maximum accrual cap of 320 hours; hours in excess of 320 hours will automatically transfer into the employees EIB.

Extended Illness Bank (EIB)

Allows for maximum accrual of 200 hours

PTO hours in excess of 320 will transfer into EIB. Employees are eligible to use EIB hours after at least 3 consecutive scheduled working days of PTO (max 24 hours) which have been used for a personal illness and/or a qualifying event under FMLA or the WA Family Care Act.

Holidays

64 hours related to:

• New Year's Day
• Memorial Day
• 4th of July
• Labor Day
• Thanksgiving Day
• Day after Thanksgiving
• Christmas Eve
• Christmas Day

Holidays are based on an 8-hour day. Providers will receive a holiday pool of 64 hours as a 1.0 FTE at the beginning of each calendar year. Holiday pool hours must be used by December 31 of each calendar year; unused holiday pool hours will be forfeited. If an employee starts after the calendar year has begun, holiday hours will be prorated based on remaining holidays in the calendar year.

Diversity Days

3 Diversity Days

Available after the first payroll cycle after start date. Diversity days will be prorated based on start date as outlined below:

• Jan 1- April 30: 3 diversity days (24 hours if 1.0 FTE)
• May 1 - August 31: 2 diversity days (16 hours if 1.0 FTE)
• Sept 1 - Dec 31: 1 diversity day (8 hours if 1.0 FTE)

Please refer to the Paid Leave policy for additional details.

403(b) Retirement Plan

Lincoln Financial

150% CVCH match up to 3% of the employee's contribution

Immediately. Vesting schedule:

20% at 2 years, 50% at 3 years, 60% at 4 years, and 100% at 5 years.

Employee Assistance Program

Mutual of Omaha

Free short-term counseling for employee and family

Immediately. Call 800-316-2796

Long-term Disability

Mutual of Omaha

Employee Only (variable)

First of the month following the first date of employment.

Benefit:

Coverage:

Effective:

Basic Term Life

Mutual of Omaha

Employee Only (1x annual salary, up to $200,000)

First of the month following the first date of employment.

Group Accidental Death and Dismemberment (AD&D)

Mutual of Omaha

Employee Only (1x annual salary, up to $200,000)

First of the month following the first date of employment.

Supplemental Term Life

Mutual of Omaha

Employee / Spouse / Dependent(s)

First of the month following the first date of employment.

Voluntary AD&D

Mutual of Omaha

Employee / Family

First of the month following the first date of employment.

Health Reimbursement Arrangement

RedQuote

Reimbursement for out of pocket expenses for services received at CVCH (medical, dental, and prescription) by employees and their dependents enrolled in our medical plan. Up to $750 per family per year.

First of the month following the first date of employment.

Flex Plan: Medical

RedQuote

Flex Plan: Maximum $3,400 per year

Direct Deposit available

First of the month following the first date of employment.

Flex Plan: Dependent Care

RedQuote

Flex Plan: Maximum $7,500 per year

Direct Deposit available

First of the month following the first date of employment.

AFLAC

Supplemental insurance - cafeteria plan

First of the month following the first date of employment.

Wellness Stipend

CVCH will reimburse staff up to $30 per month for a local gym membership

OR

CVCH will reimburse up to $150 per year for a subscription type workout program service (i.e.: Beachbody on Demand, Les Mills, etc.)

Immediately. Once employee has submitted invoice to HR/Payroll department.

Cell Phone Discounts

Discounted monthly access fees

Discounted select accessories and special equipment

Available for personal cell phones, currently in place with AT&T & Verizon

Benefit:

Coverage:

Effective:

Tuition Reimbursement

For approved courses, the cost of tuition, books, and lab fees may be reimbursed at 75% of the actual costs up to a maximum of:

• $4,000 for an Associate's degree, vocational, technical, or certification program
• $6,000 for a Bachelor's degree
• $8,000 for a Master's degree

Upon approval; regular employees who work at least 20 hours per week, have successfully passed their evaluation period and are in good standing may apply.

Employees must agree to work for a period of two (2) years from the date of receipt of tuition reimbursement and obtain satisfactory completion of approved courses or Challenge Exams.