Population Health Care Manager - Days

Full Time (80 Hours Biweekly)

Days

M-F (8-4:30 pm)

Hybrid Remote Position

General Summary

Coordinates and monitors the health needs of patients under value-based care risk arrangements, such as pain, symptom management, behavioral health, DME's, home health, assistance with daily living, and/or community resources. This position works closely with patients, caregivers, family members, physicians, hospital care managers, and ancillary service providers to achieve the patient's maximum functional potential. This position provides on-going support through comprehensive assessment and care planning. This position ensures patient's cases are in compliance with regulatory guidelines.

Duties and Responsibilities

Remote Work Capable

Essential Functions:

• Utilizes Motivational Interviewing as a patient-centered technique to promote self-management of chronic conditions and improve long-term outcomes.
• Maintains a caseload of patients per department guidelines and conducts outreach according to established protocols.
• Engages patients in home, primary care offices, and other community settings as appropriate.
• Identifies, enrolls, and manages patients in Complex Care Management programs.
• Conducts Transitions of Care and proactive outreach for high-risk patients and ensures appropriate follow-up via care management, or technology.
• Develops, implements, and updates individualized care plans to optimize health outcomes and promote wellness.
• Performs medication review and uses teach-back methods to confirm patient understanding and adherence.
• Collaborates with PCPs, specialists, and hospitalists to coordinate and implement patient-centered care plans.
• Initiates and tracks referrals to internal services and community resources to support care goals.
• Provides resource management to ensure the right care is delivered at the right time and place, optimizing cost and experience.
• Assists patients in navigating personal health decisions and care preferences, including but not limited to Advance Care Planning, to ensure individualized support and goal-aligned care.
• Documents assessments, care plans, goals, and interventions in the electronic health record per accrediting body and departmental standards.

Common Expectations:

• Prepares and maintains appropriate documentation as required, while maintaining established policies and procedures, objectives, quality assessment and safety standards.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Attends meetings as required.

Physical Demands:

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Frequently
• Reaching - Rarely
• Talking - Frequently
• Hearing - Frequently
• Repetitive Motions - Occasionally
• Eye/Hand/Foot Coordination - Occasionally

Working Environment:

• Occupational Hazards - Occasionally

Travel Requirements:

• Estimated Amount: 10% - Travel required. Makes home visits.

Qualifications

Minimum Education:

• Associates Degree Required
• Bachelors Degree Preferred

Work Experience:

• 3 years Nursing experience. Required
• Experience in Care Management or Clinical Nursing specialty. Preferred

Licenses:

• Licensed Registered Nurse Upon Hire Required or
• Registered Nurse Multi State License Upon Hire Required and
• Basic Life Support Upon Hire Required

Courses and Training:

• Residency in service area. Upon Hire Preferred

Knowledge, Skills, and Abilities:

• Excellent communication and interpersonal skills.
• Proficient in SBAR technique.
• Ability to effectively present clinical information to the care team.
• Proven organizational and motivational skills.
• Ability to work cooperatively as part of a team.
• Self-motivated and dependable.
• Able to work independently.