Population Health Nurse Case Manager

CVCH•Wenatchee, WA

9h•Hybrid

About The Position

The Population Health Nurse Case Manager is vital to ensuring safe, coordinated and effective transitions of care across settings from hospital to home and between care providers for CVCH patients, families and caregivers. The work entails integrating population health management strategies with case management to improve outcomes, reduce hospital readmissions and address social determinants of health. This role supports the mission of CVCH through collaboration with internal and external care teams to improve population health outcomes. Primary responsibilities focus on transitional care planning for Medicare patients by arranging follow up appointments, home care, rehabilitation services and medication management. The nurse case manager helps identify the appropriate care setting and ensures continuity of care services in coordination with physicians, social workers, therapist and family members while ensuring transitions are safe, patient centered and aligned with improving quality and enhancing patient outcomes.

Requirements

Bachelor’s degree in nursing required.
Current RN license for Washington State required.
Minimum of three (3) years direct RN patient care required.
Provider practice or clinic health setting preferred.
English fluency required.
Strong interpersonal and communication skills.
Analytical and problem-solving abilities.
Ability to manage sensitive and confidential information.
Competence in basic computer skills.
Ability to work independently and to use critical thinking.
Ability to develop clinical judgement.
Ability to listen effectively and provide sensitive information.

Nice To Haves

Experience with Care Coordination, Case Management, Home Health or Behavior Health preferred.
Experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
Experience with health IT systems and data reports preferred.

Responsibilities

Develops, implements, and evaluates individualized, patient- and family-centered plans of care, in collaboration with primary care providers, with emphasis on transitional care following inpatient hospitalizations or emergency department visits.
Conducts comprehensive assessments of patients’ physical, emotional, social, and environmental needs to establish baseline care requirements and identify barriers to care.
Applies advanced clinical nursing expertise to support management of complex conditions, including assessment, symptom monitoring, patient education, and care coordination in collaboration with primary care providers and the interdisciplinary team care team.
Provides care coordination and clinical support within the RN scope of practice, organizational policies, standing orders, and provider-directed plans of care.
Communicates and coordinates effectively with interdisciplinary care teams to ensure accurate triage, shared understanding, and seamless management of patient needs across care transitions.
Stratifies patient populations by risk level to prioritize interventions and optimize care delivery for patients with multiple chronic conditions.
Collaborates with providers and care team to support appropriate frequency of provider visits and chronic care management encounters, based on patients’ risk and clinical needs.
Develops, maintains, and strengthens relationships with external partners and community organizations, including post-acute care providers, behavioral health services, specialty providers, and community-based resources, to support continuity of care and improved outcomes.
Coordinates with external health and human service agencies to address social determinants of health, including transportation, food insecurity, utility assistance, and welfare checks.
Leverages electronic health records, analytics, and telehealth technologies to document care, share care summaries, monitor patient progress, and support communication across the care continuum.
Monitors and evaluates patient and program outcomes, including chronic disease control and reduction of hospital admissions and readmissions, and adjusts care strategies as indicated.
Performs other duties and tasks as assigned by supervisor.
Start shift on time and meet attendance standards per the FTE assigned in HRIS system.
Follow safety policies and maintain a clean, safe work environment.
Demonstrate sound work ethics, flexibility, and cultural sensitivity.
Uphold CVCH’s mission and core values in all interactions.
Comply with CVCH policies, Joint Commission standards, and HIPPA regulations.
Participate in internal committees, department huddles, department meeting or special projects.