PCHH RN Care Manager

Four Rivers Community Health Center•Rolla, MO

6d•$26 - $37

About The Position

The PCHH RN Care Manager is an exempt position accountable to the RN Population Health Programs Director. The role develops and manages care for Primary Care Health Home patients, performs program duties within the scope of a Missouri-licensed Registered Nurse, and assists and directly supervises team members performing care management and related program support. The position coordinates care among patients, primary care and specialty care teams, and inpatient facilities. It uses nursing assessments, evidence-based resources, and health information systems to coordinate individual care and manage population health, including social determinants of health, chronic disease management, emergency department utilization, and hospital admissions. The role also evaluates program effectiveness and care gaps using data, and participates in and leads quality improvement initiatives. The RN Care Manager is expected to protect patient information, communicate effectively with patients and partners, and provide customer service consistent with Four Rivers Community Health Center’s mission, vision, values, and AIDET guidelines. Reliable transportation is required, as are off-site training and meetings and nonstandard hours as needed.

Requirements

Degree qualifying the candidate to sit for the NCLEX and become a Registered Nurse.
Minimum three years of experience as a Registered Nurse.
Missouri Registered Nurse licensure, as indicated by the requirement to perform duties within the scope of a state of Missouri licensed RN.
Reliable transportation.
Ability to attend off-site training and meetings and work nonstandard hours as required.

Nice To Haves

BSN or MSN preferred.
One year of experience in case management, care coordination, or program management preferred.

Responsibilities

Develop and manage care for Primary Care Health Home patients.
Build direct relationships with patients and coordinate care with primary care teams, specialty care teams, and inpatient facilities.
Develop care plans, monitor medication adherence and reconciliation, and identify and address high utilizers.
Assist and directly supervise team members performing care management and support functions for PCHH and related programs.
Apply critical thinking in complex situations in accordance with Four Rivers Community Health Center’s mission, vision, and values.
Safeguard patient information in accordance with HIPAA and applicable guidelines.
Communicate with patients, administrative and multidisciplinary team members, and community partners.
Use evidence-based guidelines, literature, program assistance letters, official manuals and regulations, and nursing assessments to coordinate individual care and manage population health.
Use the EHR, DRVS, Cyber Access, eMOMED, HIE-connected portals, and other applicable data sources to obtain patient information and evaluate population health program effectiveness.
Extract, analyze, and interpret data from health information sources to identify and address care gaps and support positive patient outcomes.
Participate in and lead population health quality improvement initiatives related to organizational quality measures and compliance requirements, including MPCA, MCOs, HEDIS, and UDS.
Provide customer service consistent with Four Rivers Community Health Center core values and AIDET.
Attend off-site training and meetings and work nonstandard hours as required to perform the position’s duties.
Perform other duties as assigned.