Registered Nurse Care Manager - Community Care Team

Montana Primary Care Association•Missoula, MT

47d•Onsite

About The Position

This position will work in a clinic setting and provide outreach to people living outside unsheltered. Exposure to the elements in a non-traditional setting is expected. Partnership Health Center (PHC) is currently in the process of separating from Missoula County, with completion expected by the end of this year. As a result, our employee benefits package will be changing as early as January 1, 2026. While final details are not yet available, the future benefits are expected to remain comparable in value and scope to our current offerings. We are committed to keeping everyone informed and supported throughout this change and will update postings regularly. Located halfway between Yellowstone and Glacier National Parks and home to the University of Montana, Missoula is an academic center situated in an outdoor enthusiast's paradise. Depending on the season, you can hike, ski, fish, float rivers, ride mountain bikes, or just sit back and marvel at the surrounding scenery. Join us in scenic, sophisticated, and service-oriented Missoula! Partnership Health Center (PHC), 2019 and 2022 winner of the Employer of Choice Award for Missoula, and 2022 winner of the Montana Employer of Choice Award, offers impeccable, integrated services to over 18,000 individuals and families. A 14-site, co-applicant Federally Qualified Health Center with Missoula County, PHC fulfills its mission through the provision of a full range of primary care services - medical, dental, behavioral health, and an on-site pharmacy with a dedication to attending to the social determinants of health. Please visit our website to see the amazing benefits you will receive by joining our team such as medical (no cost for employee), dental, and vision insurance, loan forgiveness, retirement plan contributions, and generous paid sick and vacation time. DEFINITION: Performs work as a registered nurse, as a member of primary care medical teams to provide care management throughout a multiple county region for the Partnership Health Center (PHC).

Requirements

EDUCATION: Requires graduation from an ACEN (Accreditation Commission for Education in Nursing) approved program.
EXPERIENCE: Requires one year of experience in providing chronic disease management and interventions with clients.
SPECIAL REQUIREMENTS: Requires current license to practice as a registered professional nurse in Montana.
Subject to passing a criminal background investigation that will require fingerprinting.
Requires a current Healthcare Professional BLS certification or the ability to obtain it within 90 days of hire.
Requires immunizations or proof of immunity to certain infectious diseases and a TB test.
New employees will be asked to volunteer vaccination status for required vaccines upon hire and will be offered assistance during hiring to receive necessary immunizations.
Employees who have not received the vaccines required for their positions or who are unwilling to voluntarily provide vaccination status for required vaccines will receive a reasonable accommodation where such accommodation does not require an undue hardship or endanger the health or safely of any person.
KNOWLEDGE: Working knowledge of quality management processes.
Working knowledge of client confidentiality, and the ethical and legal requirements of the profession.
Working knowledge of nursing practices related to acute and chronic complex medical conditions such as cancer, cardiac disease, pulmonary disease, diabetes, and chronic pain conditions.
Working knowledge of chronic disease self-management strategies.
Working knowledge of the principles and practices of HIPAA compliance.
Working knowledge of the PHC Corporate Compliance Guidelines.
SKILLS: Skill in the use of a personal computer including electronic medical records, word processing, spreadsheets, email and data base software.
ABILITIES: Ability to coordinate complex medical care plans consistent with the chronic disease self-management model.
Ability to gather and analyze data and make appropriate recommendations to the medical care team.
Ability to communicate in the English language, orally and in writing.
Ability to establish and maintain effective working relationships with diverse individuals and groups.

Responsibilities

Maintains an active patient caseload.
Develops strategies with the care team consistent with a patient-centered medical home to manage complex medical needs for clients with complex medical conditions.
Works within the PHC model for chronic disease self-management to provide patient and family education and develop goals that result in improved health outcomes.
Develops comprehensive care plans and provides documentation as appropriate or required.
Makes visits to clients in their homes or at other locations outside the PHC as necessary.
Establishes a quality measurement system for all clients in the individual caseload to objectively measure client outcomes, compare and analyze disease burdens, and predict medical expense.
Coordinates hospital discharges with client, family, and hospital care team.
Participates in multi-disciplinary conferences, serving as a clinical resource for medical providers, dental, mental health and psycho-social case managers.
Provides clinical work directions for Licensed Practical Nurses and Medical Assistants, serves as a clinical resource, and contributes to performance management efforts.
Performs related duties as required or directed.