Population Health Nurse Supervisor

COQUILLE INDIAN TRIBE•Coos Bay, OR

7d•$92,706 - $115,877•Hybrid

About The Position

Under the direction of the Health and Wellness Division (HWD) Chief Operating Officer (COO), the Population Health Nurse Supervisor provides leadership, supervision, and clinical guidance to the Population Health Nurse Case Management team. This position fosters collaboration across the healthcare system to promote the delivery of high-quality, culturally responsive, patient-centered, and cost-effective care. The Population Health Nurse Supervisor is responsible for developing, implementing, and leading the Health and Wellness Division's Population Health Case Management Program, utilizing a population health approach to improve health outcomes for patients served by the Ko-Kwel Wellness Center (KWC) across all locations. The position allocates approximately 30% of time to administrative, supervisory and operational responsibilities and 70% to providing comprehensive nurse case management and care coordination for patients with chronic, complex, and high-risk health conditions. Regular travel between KWC locations is required to support staff and provide patient services.

Requirements

Licensure as a Registered Nurse in Oregon.
Associate Degree of Nursing.
Minimum 2 years of supervisory experience.
Minimum 3 years’ experience working in quality improvement, population health, case management or utilization management.
Case Management certification, or the ability to obtain certification within six (6) months of hire.
In lieu of certification at the time of hire, candidates must have at least three (3) years of direct case management experience.
Excellent written and verbal communication skills required.
Proficiency in Microsoft Office applications (including Outlook, Word, Excel, and PowerPoint) and the ability to effectively use electronic health record (EHR) systems and other applications.
Experience with electronic health records (EHR).
Willingness and ability to adapt individual interventions, programs, and policies to fit the cultural context of the individual, family, or community.
Current and valid Oregon driver’s license in good standing is required with no insurability restrictions from the Tribe’s insurance carrier.

Nice To Haves

Bachelor of Science degree in nursing, preferred.
Experience with EHR population health, integrated chronic disease management and patient portal software preferred.
Previous OCHIN-Epic experience.
Knowledge of Native American culture.

Responsibilities

Provide leadership, supervision, and performance management for the Population Health Nurse Case Managers and other case management staff, including Traditional Health Care Workers, as the program expands.
Develop, implement, and maintain policies, and standard operating procedures (SOPs) for the Nurse Case Management Program to ensure consistency, quality, and compliance.
Lead the development, implementation, and ongoing evaluation of the Health and Wellness Division's Nurse Case Management Program, ensuring continuous quality improvement, regulatory compliance, and alignment with organizational goals.
Develop and oversee communication strategies and program resources to promote Nurse Case Management services to patients, providers, and community partners through appropriate communication channels.
Develop, implement, and continuously improve workflows and processes that support accurate documentation, coding, billing, and insurance reimbursement.
Identify alternative funding opportunities, including grants, partnerships, and reimbursement initiatives, to support the long-term sustainability of the Nurse Case Management Program.
Serve as the primary point of coordination among patients, healthcare providers, specialists, hospitals, and community resources to ensure seamless, patient-centered continuity of care.
Utilize Electronic Health Record (EHR) population health reports and other available data to identify patients at high risk or with chronic and complex medical conditions who may benefit from case management services.
Collaborate with interdisciplinary care teams to develop, implement, and optimize population health initiatives that improve patient outcomes.
Develop and maintain a process for identifying and enrolling high-risk patients in case management services.
Conduct comprehensive assessments, develop individualized care plans, and collaborate with patients, families, and the healthcare team to coordinate services, address barriers to care, and achieve optimal health outcomes.
Advocate for evidence-based treatment and interventions by applying current clinical guidelines and best practices in care management.
Monitor patient progress and revise care plans as needed to address changing healthcare needs.
Maintain appropriate and essential resources, procedures, and policies to ensure the delivery of high-quality nurse case management services.
Assess patients' ability to access healthcare services and identify barriers to care, including transportation, food insecurity, financial challenges, housing instability, and other social determinants of health.
Connect patients with appropriate internal and community resources to address identified health, social, and support needs and promote continuity of care.
Provide patient and family education regarding disease prevention, chronic disease self-management, medication adherence, and healthy lifestyle practices.
Coordinate transitions of care for patients discharged from hospitals, emergency departments, skilled nursing facilities, or other care settings.
Ensure timely follow-up, medication reconciliation, and coordination of post-discharge services to reduce avoidable readmissions.
Maintain policies, procedures, and clinical guidelines that support effective, compliant, and high-quality nurse case management services for patients of the Ko-Kwel Wellness Center in collaboration with KWC Leadership team
Coordinate medical appointments, referrals, specialty care, and ancillary services while serving as a patient advocate to improve access to care and facilitate communication among providers and community partners.
Participate in quality improvement and patient safety activities for improving care and outcomes for patients.
Document patient assessments, interventions, care plans, education, coordination activities, and outcomes accurately and timely within the Electronic Health Record (EHR).
Maintain accurate patient problem lists, preventive health screenings, health maintenance records, and other clinical documentation within the EHR.
Creates and manages patient panels within OCHIN Epic Population Health to support chronic disease management, preventative care and wellness initiatives.
Participate in HWD meetings as requested.
Other duties as assigned.