Population Health Nurse Care Manager

RiverStone Health•Billings, MT

7d•$35 - $50•Onsite

About The Position

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. The role also supports RiverStone Health’s participation in quality and value-based care initiatives. The position coordinates with the Patient Care Team in a Patient Centered Medical Home model to support effective, high-quality, coordinated services. It also works with community care partners to support smooth transitions between agencies. The role works under the direction of the Population Health Program Manager and exercises independent professional judgment regarding patient health within established regulations and nursing practices. This is a 32-hour-per-week, non-exempt position scheduled Monday through Friday, 9:00 a.m. to 4:30 p.m. Work is primarily performed in a clinical office setting, with occasional travel to patient homes and community settings. The wage range is $34.52–$50.04 per hour, depending on transferable experience and internal equity.

Requirements

Graduation from an accredited registered nursing program.
Two years of clinical nursing experience; chronic disease management, ambulatory care, care coordination, home health, or transitions of care experience is preferred within this qualification.
Excellent assessment and triage skills.
Excellent communication and interpersonal skills.
Current Registered Nurse license in good standing in the State of Montana.
Valid State of Montana Driver’s License.
BLS Certification.
Computer literacy, including Microsoft Office Suite and accessing and querying electronic health records.
Knowledge of current population health practices and disease-specific standards of care.
Ability to identify disparities and develop programs or interventions to help reduce them.
Knowledge of care planning, SMART goal setting, chronic disease self-management coaching, and physical and mental health assessment techniques.
Ability to understand and follow HIPAA regulations and practices.
Ability to organize resources, establish priorities, prepare reports, and make presentations according to prescribed standards.
Ability to follow verbal and written policies, procedures, and instructions.
Ability to establish and maintain effective working relationships with patients, employees, supervisors, community service representatives, and the public.
Ability to work collaboratively toward shared goals, independently, and in an organized, self-directed manner.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Experience in care management, population health, FQHC practice, or working with patients experiencing complex medical and social needs.

Responsibilities

Maintain an assigned caseload of high-risk patients and prioritize services according to clinical acuity, utilization, barriers to care, and patient goals.
Review referrals and population health reports to identify appropriate patients, explain care management services, and engage patients in ongoing participation.
Perform and document comprehensive initial assessments covering physical and behavioral health, medication use, functional status, health literacy, social and financial needs, access barriers, patient strengths, and caregiver support.
Develop and maintain individualized, patient-centered care plans with patients, caregivers as appropriate, primary care providers, and the interdisciplinary team, including measurable goals, interventions, responsible team members, and follow-up intervals.
Educate and coach patients and caregivers on chronic conditions, prevention, medication adherence, symptom monitoring, healthy behaviors, and use of supplies and equipment; use goal setting and self-management strategies to support self-care.
Coordinate with the Transitions of Care team to identify patients needing ongoing management after hospital or emergency department encounters, and provide assessment, medication reconciliation, self-management support, and follow-up coordination.
Collaborate with panel managers, scheduling staff, and clinical teams to address care gaps requiring nursing assessment, education, or clinical coordination.
Conduct occasional home visits to assess needs, provide education and self-management support, and coordinate care.
Perform and document ongoing reassessments, monitor progress, update care plans, communicate concerns and recommended treatment changes to treating providers, and implement orders and approved protocols within RN scope of practice.
Document care management activities, required patient consent, and service time accurately and promptly; collaborate with billing staff to support appropriate coding and reimbursement under payer requirements.
Implement evidence-based care, chronic disease protocols, and guidelines; use registries to identify patients with chronic conditions and clinical care gaps and ensure appropriate follow-up.
Support value-based care and population health initiatives and participate in health center quality improvement activities.
Coordinate with other care managers and disciplines to clarify responsibilities, facilitate warm handoffs, and maintain coordinated care plans.
Identify education and training opportunities, act as a resource for clinic staff, and share educational materials and other resources.
Participate in developing, implementing, and evaluating care management workflows.
Track patient goals and population health outcomes and participate in improvement activities when expected results are not achieved.
Perform other duties as assigned in support of the organization’s mission and goals.
Use time, supplies, and resources efficiently to support cost-effective operations.