Population Health Manager Jobs

About The Position

Requirements

• Graduated from an accredited nursing school or college.
• Bachelor of Science in Nursing (BSN) required.
• Current California State RN License required.
• Minimum of two years of relevant clinical experience required.
• Minimum of one year of case management experience required; equivalent case management education and/or experience will be considered.
• Obtain Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification within two years of starting the position.
• Knowledge of personal computers, data entry and retrieval, and MS Suite software, specifically MS Word, or good keyboard skills.
• Ability to communicate effectively with patients, physicians, healthcare personnel, supervisory staff, and peers.
• Ability to organize, prioritize, and manage assignments efficiently with minimal oversight and direction.
• Willingness to research, learn, and acquire knowledge needed to perform the position.
• Professional and courteous demeanor and ability to work collaboratively while maintaining positive relationships.
• Critical-thinking ability and sound clinical judgment and assessment skills.
• Knowledge of NCQA, DHS, CMS, JCAHO, and EMTALA standards and federal and state regulations.
• Knowledge of acute care, home care, subacute care, long-term care, hospice interventions, rehabilitation options, and community resources and requirements.
• Knowledge of Milliman and InterQual medical necessity guidelines.
• Expert knowledge of CPT and HCPC codes and related guidelines.
• Expert knowledge of ICE guidelines governing TAT, claims, and the denial process.
• Knowledge of current healthcare standards and trends, best practices, management tools, and related resources and literature.
• Knowledge of capitation and managed care legislation.
• Knowledge of CMSA Standards of Practice.
• Ability to meet the physical demands of the job, including regular walking, stooping, bending, twisting, periods of sitting and standing, and computer keyboarding.

Nice To Haves

• Master’s degree in nursing or another health-related field preferred.

Responsibilities

• Identify high-risk patients by reviewing EHR referrals and referrals or reports from the ED, pharmacy, hospital, and other departments or systems.
• Assess member needs and develop specific care plans addressing identified objectives, barriers, goals, strengths, and opportunities.
• Evaluate patients’ physical, behavioral, and social support capacities and their engagement with providers.
• Follow up with patients and providers on identified healthcare needs and coordinate resources, including through multidisciplinary care management.
• Facilitate and manage referrals from referral specialists, providers, and care management staff to ensure red flags and healthcare needs are addressed.
• Provide individual health education consultations and promote health awareness among individuals, groups, and organizations.
• Provide oversight and implement care plans and patient education in accordance with established policies and procedures.
• Identify at-risk individuals and apply clinical guidelines to develop comprehensive plans of care.
• Obtain and evaluate relevant medical, psychosocial, and financial information using interviewing skills.
• Advocate for patients and families throughout their episodes of care and facilitate communication among providers.
• Meet with patients and families when appropriate, provide information about suitable providers, and involve patients and support systems in decision-making.
• Use established processes to assess patients’ understanding and acceptance of proposed plans, readiness to change, and support for maintaining health behavior changes.
• Apply teaching and learning theories to help patients and families address the physical and emotional effects of body changes and chronic illness.
• Document and communicate with providers and care team members to minimize fragmented care, including during transitions from hospital to home or community facilities.
• Use problem-solving and conflict-resolution skills to support consistent, quality patient care.
• Participate in department quality monitoring and improvement, such as audits, training, and assigned projects.
• Analyze case management effectiveness in relation to patient outcomes, fiscal parameters, customer satisfaction, and system operations; communicate performance improvement strategies to the UM Manager and Director of Care Management as appropriate.
• Manage patient care through healthcare systems according to individual needs and collaborate with physicians and healthcare providers on plan changes.
• Develop individualized comprehensive plans of care with physicians, Social Services, and the interdisciplinary team.
• Track patient pathways through identification and assignment of DRG and communicate the anticipated discharge date to patients, families, physicians, and staff.
• Proactively communicate with, assess, and reassess patients throughout their hospital stay and develop alternative discharge plans when indicated.
• Transition patients to the next appropriate level of care, involving outpatient case management or other resources as appropriate.
• Remain involved until the patient is discharged from the hospital or the case management function is transferred to outpatient services.
• Perform other duties as assigned to meet the needs of the population managed.
• Adhere to established policies and procedures and meet attendance and punctuality standards.