Population Health Nurse Care Manager

RiverStone Health•Billings, MT

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 with patients, families, primary care providers, and the interdisciplinary care team, the RN assesses patient needs, develops individualized care plans, supports chronic disease self-management, coordinates services, and monitors progress toward patient-centered goals. The role uses clinical information, risk stratification, and population health data to prioritize outreach, close care gaps, improve health outcomes, and support quality and value-based care initiatives. The position maintains a high-risk patient caseload; reviews referrals and population health reports; conducts comprehensive assessments and follow-up; provides education and coaching; and coordinates care across clinical teams, community partners, and care settings. Occasional home visits may be conducted as appropriate. The role also contributes to quality improvement, care-management workflows, and population health initiatives. 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 in a clinical office, with occasional travel to patient homes and community settings. The position reports to the Population Health Program Manager and has no supervisory responsibilities. The hourly wage range is $34.52–$50.04, depending on transferable experience and internal equity.

Requirements

Graduation from an accredited registered nursing program.
Two years of clinical nursing experience.
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 the ability to access and query electronic health records.
Knowledge of current population health practices, disease-specific standards of care, care planning, SMART goal setting, chronic disease self-management coaching, and physical and mental health assessment practices.
Ability to identify disparities and develop programs or interventions to help reduce them.
Ability to understand and follow HIPAA regulations and practices.
Ability to organize resources, establish priorities, prepare reports and presentations, and follow policies, procedures, and instructions.
Ability to establish and maintain effective working relationships with patients, employees, supervisors, community organizations, and the public.
Ability to work toward shared team goals and independently, while remaining organized and self-directed.
Commitment to the stated customer service practices, including professionalism, respect, responsiveness, protecting confidentiality, and taking ownership of service quality.

Nice To Haves

Clinical nursing experience involving chronic disease management, ambulatory care, care coordination, home health, or transitions of care.
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, care barriers, patient strengths, and caregiver support.
Collaboratively develop and maintain individualized, patient-centered care plans with patients, caregivers as appropriate, primary care providers, and the interdisciplinary care team.
Establish measurable goals, planned interventions, responsible team members, and follow-up intervals.
Provide patient and caregiver education and coaching on chronic conditions, prevention, medication adherence, symptom monitoring, healthy behaviors, and the use of supplies and equipment.
Use patient-centered goal setting and self-management strategies to build patients’ confidence and capacity for self-care.
Collaborate with the Transitions of Care team to identify patients needing ongoing care management after hospital or emergency department encounters.
Provide continued assessment, medication reconciliation, self-management support, and coordination of follow-up services for assigned patients.
Collaborate with panel managers, scheduling staff, and clinical teams to address care gaps requiring nursing assessment, education, or clinical coordination.
Conduct occasional home visits, as appropriate, to assess needs, provide education and self-management support, and coordinate care.
Reassess patients at intervals based on their needs and applicable program requirements; monitor progress, update care plans, communicate concerns and recommended treatment changes to providers, and implement orders and approved protocols within RN scope of practice.
Complete accurate and timely documentation of care-management activities, required patient consent, and service time; collaborate with billing staff to support appropriate coding and reimbursement.
Implement evidence-based care, chronic disease protocols, and guidelines.
Use registries to identify patients with chronic conditions and gaps in clinical care, and ensure appropriate follow-up.
Monitor individual patient progress and population health management, and assist with value-based care and population health initiatives.
Participate in health center quality improvement activities and in developing, implementing, and evaluating care-management workflows.
Coordinate with other care managers and disciplines to clarify responsibilities, facilitate warm handoffs, and maintain coordinated care plans.
Identify education and training opportunities, disseminate educational materials and resources, and serve as a resource for clinic staff in problem solving.
Track patient goals and relevant 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.