Nurse Care Manager

Description

Job Description

Job title:

Nurse Care Manager

Location:

Agency Wide

Terms:

Perm/Full-time/Salary

About the role:

The Nurse Care Manager (NCM) is the population health backbone of the CRSOK Medical Clinic. Rather than carrying a traditional patient caseload, the NCM operates from a registry-driven model-working proactively across the active patient population to ensure physical health screenings, metabolic monitoring, and care coordination are completed at required intervals. This role is central to CCBHC compliance and directly supports PPS billing accuracy, quality improvement reporting, and ODMHSAS fidelity review metrics.

Responsibilities:

Own and maintain the CRSOK monitoring registries for all active medical clinic patients

Work the registry as a structured weekly worklist to identify overdue screenings, labs, and care gaps

Provide monthly registry summary reports to the Medical Director with compliance rates and trend data

Coordinate with QA/QI to ensure registry data feeds CCBHC NOMs, HEDIS, and PPS reporting

Review next-day appointments and flag charts in Arize with pending labs, overdue screenings, or abnormal results

Track and coordinate metabolic monitoring intervals per psychotropic medication class

Order and coordinate labs per standing orders to ensure results are available before prescriber visits

Document all clinical data in Arize structured fields

Flag abnormal results to prescribers within 24 hours; maintain the Abnormal Result Tracking Log

Maintain infectious disease screening registry per USPSTF and CCBHC requirements

Run monthly no-PCP list and submit to case management

Complete 7-day post-discharge follow-up calls and monitor HIE for admissions and ED visits

Work weekly recall lists for overdue patients; conduct outreach and escalate as needed

Support CCBHC NOMs reporting, HEDIS reconciliation, and PPS billing accuracy reviews

Participate in chart audits as directed

Lab Director:

• Organization Laboratory Director over four facilities, confirming CLIA waived testing is approved and recorded. Responsible for monitoring appropriate training, documentation, and quality controls of each CLIA waived test daily to monthly at each facility.
• Familiarize oneself with Ready Set Test Booklet from CLIA 56 pages detailing appropriate, safe, legal, patient testing.
• Apply for CLIA Waived testing certification at all facilities - Riverbridge, Sand Springs, YES Tulsa, and Calm Center
• Confirm that each test done at each facility is CLIA Waived and then submitted to CLIA under that address.
• Confirm there is documented training on each testing done at each facility.
• Confirm there is a quality control (QC) product purchased on each testing done at each facility.
• Confirm the quality controls are being completed and recorded
  • Some tests, blood glucometer requires daily QCs (or each use) other tests, HIV testing require monthly QCs.

Phlebotomist:

• Verifies test request per standing orders or special orders from the physician and/or nurse practitioners, bringing discrepancies to the attention of the supervisor. A, B, C, D, E
• Verifies client's identity as indicated in agency procedure. Correctly identifies client specimens according to established laboratory protocols. A, C, D, E
• Obtains blood specimens by performing venipunctures and finger sticks. A, E
• Successfully collect venipuncture and capillary samples with minimal discomfort to the patient. A, B, C, E
• Perform blood draws, clearly labeling specimens, recording maintenance data and decontamination, updating client information, etc., A, D, E
• Maintains specimen integrity by using aseptic techniques, following department procedures. A, D, E
• Maintains quality results by following department procedures and testing schedule; recording results in the quality-control log; identifying and reporting needed changes in El-IR. A, D, E
• Resolves unusual test orders by contacting the physician or nurse practitioner referring unresolved orders back to the originator for further clarification, notifying supervisor of unresolved orders. A, B, C, D, E
• Maintains safe, secure, and healthy work environment by following standards and procedures, complying with legal regulations and standards. A, D, E
• Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in, professional organizations. A, D, E
• Serves and protects the agency community by adhering to professional standards, agency policies and procedures, federal, state, local requirements, and CARF or other standards. A, D, E

Candidate R equirements:

• Active, unrestricted license, Oklahoma Board of Nursing required; NPor APRN accepted
• Minimum 2 years nursing experience; population health or care management experience preferred
• Comfort working from a data and registry model rather than reactive encounter-based care
• Experience with EHR structured data entry-Arize experience a plus
• Strong organizational skills with ability to manage a structured worklist across a large population
• Familiarity with CCBHC quality metrics, HEDIS, or population health reporting preferred
• Comfort working with patients with serious mental illness and co-occurring disorders
• Strong written documentation skills

Direct Supervises: None