Nurse Care Manager - Engebretsen Clinic

Primary Health Care Inc•Des Moines, IA

4h•Onsite

About The Position

As a Nurse Care Manager at PHC, you will implement risk stratification strategies to identify patient populations requiring higher-level care management, disease/chronic condition management, and psychosocial support, and you will provide holistic care management and coordination for those patients with complex needs. You will work as part of our interdisciplinary care team to meet the changing needs of our patients. All team members must demonstrate PHC iCare values in daily work. This position typically works at PHC Engebretsen Clinic in Des Moines and is scheduled Monday - Friday 7:30 AM - 4:00 PM. This position occasionally travels to other sites for meetings. Our team members are occasionally needed to cover other shifts or to work at other PHC clinics in Ames, Des Moines, and Marshalltown. Mileage reimbursement and/or an out of town travel bonus may apply.

Requirements

Completion of an accredited nursing program accepted by the Iowa Board of Nursing for licensure.
Verbal and written communication skills, including the ability to provide effective education to others.
Interpersonal skills and the ability to maintain professional relationships with a wide variety of people.
Ability to work collaboratively and autonomously.
Commitment to service excellence.
Self-motivated and takes initiative.
Active listening skills and a willingness to take direction.
Problem-solving skills with the ability to apply critical thinking and assessment within a nursing framework.
Time management skills with the ability to efficiently move between tasks.
Consistently meets the department work schedule as assigned.
Detail oriented.
Proficiency using electronic health records, Microsoft Office applications and internet-based applications.
Adheres to patient confidentiality standards.
Ability to consistently meet care manager measures and acceptable performance standards.
Current RN license recognized by the State of Iowa; Current Basic Life Support (BLS) for Healthcare Providers; Current Mandatory Reporter Training: Child Abuse and Dependent Adult Abuse recognized by the State of Iowa (Must be obtained within the Introductory Period if not current).

Nice To Haves

Bachelor of Science in Nursing.
Experience in a community health center or public health organization.
Experience with population health, care management/coordination, the Chronic Care Model, health registry systems, or community resources.
Spanish language skills, written and verbal.

Responsibilities

Utilizes Interventions for Population Health Management to maximize the health and recall opportunities for patients who are care-managed, part of the Accountable Care Organization contracts, or warm hand-offs from PHC providers with complex needs. Addresses the medical, psychosocial, health risk, prevention, wellness, and education needs of the patient and/or family.
Utilizes the RN-led Visit Model, including nursing assessment, diagnosis, planning, implementing, and evaluation of nursing care plans. Provides care management, care coordination, chronic disease and preventive screening and education for patients and/or families.
Supports PHC Way initiatives and actively assists in pre-visit planning, post-visit follow-up, and care coordination. Executes the strategy for planned visits, including appropriate health prevention and screening activities.
Participates in Accountable Care Organization activities such as value-based care and shared savings initiatives, completes Medicare Annual Wellness Visits and Medicaid recall care coordination, and provides chronic care, disease management, and complex care management.
Documents patient care accurately and timely in the electronic health record.
Assists with panel assignments and workload, support teams to balance the complexity and continuity of care needs of patients and the care teams.
Performs nursing triage of acute medical issues for clinic patients as needed, refers or monitors appropriately.
Utilizes data systems and reporting to monitor population health management patient outcomes and identify gaps in care.
Participates in grant-related clinical initiatives.