Care Management Lead RN

Job Description

Job Description

Vacancy Posting

PureView Health Center has a career opportunity for a  Full-time, Care Management Lead RN.  This   opportunity, located in Helena, Montana is within the Nursing department and reports to the Clinic Nurse Manager.

Make an Impact on Our Community

  PureView is dedicated to providing the communities we serve with quality, patient-centered, accessible healthcare with comfort. We strive in each encounter to be the leading provider of the highest quality healthcare for our community regardless of a person’s circumstance.

At PureView, we value treating our patients, their families and our colleagues with compassion, kindness, and respect. We customize our care according to patient needs and values. And we believe in employing talented, skilled, caring, and responsible people. To us, treating each patient with dignity and as an individual is essential.

Key Responsibilities:

  Under the general supervision of the Clinic Nurse Manager, the Care Management Lead is responsible for the use of advanced nursing processes of risk stratification to identify high-risk, acutely ill, and chronic disease patients. The goal of this position is to optimize the patient’s health status and improve health outcomes through coordination of care, self-management support, patient education, and collaboration with the interdisciplinary care team. The Care Management Lead is responsible for assessing, planning, implementing, evaluating, and managing individualized services for patients to ensure the delivery of quality patient-centered care, continuity of care, and the delivery of cost-effective healthcare services. The Care Management Lead assists patients, families, and caregivers in securing services, medications, equipment, and community resources to optimize the patient’s health status. 

The Care Management Lead oversees the value-based contracts and assigns and oversees completion of related reports. The Care Management Lead serves as a resource/mentor to the full Care Management Team. The Care Management Lead assesses and ensures the quality of work performed by the full Care Management Team and reports to the Clinic Nurse Manager.

Duties and Responsibilities

• Identifies the targeted high-risk patient population per risk stratification, PCP referral, and inpatient and Emergency Department tracking. Includes patients with repeated health crises and who are likely to benefit from care management.
• Provides transitional care management for patients who have been admitted to the hospital. Completes timely post-hospital follow up: Medication reconciliation, PCP or specialist follow up appointment, review discharge instructions, coordination of care as needed, and problem solve barriers.
• Provides tracking of patients who are seen in the Emergency Department, including outreaching patients for follow up as needed, and outreaching for follow up appointments as needed.
• Provides transitional care management for patients who are being discharged from skilled nursing facilities and discharged from inpatient healthcare settings.
• Provides chronic care management including health and disease management education, goal setting, self-management support education and coaching for patients identified through risk stratification and tracking processes.
• Provides education on disease processes and prevention strategies.
• Collaboratively creates care plans with patients enrolled in the Chronic Care Management program.
• Provides coaching and support with patients enrolled in Chronic Care Management; support patients in goal setting and self-management, revise treatment plan as needed, adjust treatment per guidelines or per provider recommendations, communicate treatment changes with PCP, continue follow up until patient meets goals or opts out of care management.
• Collaborates with the primary care providers, specialty care providers, and medical staff to create and confirm treatment goals, treatment plan, and clinical outcomes used to monitor progress and complete the individualized plan of care.
• Monitors lifestyle factors affecting health; tobacco use, substance abuse, nutrition and physical activity. Assists the patient with goal setting to achieve behavioral change. 
• Performs and documents for an intake assessment which includes obtaining and reviewing prior medical records, financial data, medical history, cognitive/verbal skills and needs, and identifying barriers to accessing healthcare.
• Provides individual and family educational interventions including self-management, goal setting, counseling and training on habits, lifestyle changes, supplies and tools necessary to manage their disease with a focus on empowering the patient and family to build capacity for self-care.
• Identifies potential financial barriers towards achieving optimal health. Makes appropriate referrals and utilizes community resources to resolve barriers.
• Coordinates patient care by linking patients to resources, including community resources. Works closely with Case Management.
• Implements evidence-based care, chronic disease protocols and guidelines. Utilizes registry to identify patients with chronic conditions, and gaps in clinical care. Ensures appropriate follow-up addressing care gaps. Monitors individual patient progress and population management.
• Oversees value-based care contracts.
  • Outreaches patients for annual wellness visits, including Medicare annual wellness visits.
  • Outreaches patients identified as having care gaps to ensure engagement in care and provision of preventive services.
  • Possesses the ability to use electronic software applications related to care management activities.
  • Delegates and oversees reports related to value-based care contracts.
  • Maintains reports for MPCA and insurance payors as required per value-based care contractual obligations.
  • Monitors and reports on quality of care for patients attributed to PureView Health Center.

• Participates in the PureView Health Center’s quality improvement activities to enhance care management in the office setting. 

• Promotes and assists in the smooth, efficient delivery of care to patients. Promotes patient relationships with their primary care team. Participates in regular staff meetings focused on coordinating patient care within an interdisciplinary team.
• Identifies education/training opportunities in support of health improvement initiatives. Acts as a resource for clinic staff for problem solving. Disseminates educational materials and other resources.
• Manages development and implementation of care management activities.
• Designs and implements an initial training program for all new care management staff.
• Provides appropriate coaching and learning opportunities when necessary.
• Provides resources for care management teams to effectively perform their roles.
• Works to unite all care management team members through training, standardization, and creating a culture of teamwork focused on patient-centered care.
• Works collaboratively with the QI Team and Compliance Team to ensure compliance with HRSA requirements and reporting including UDS.
• Works collaboratively with the billing/coding team to ensure appropriate documentation and processes for billable services. 
• Works collaboratively and develops relationships with community partners to coordinate care for patients. 
• Familiarity with, adheres to, and ensures policies and procedures related to care management services are maintained and followed by care management team. 
• Furthers the mission of PureView Health Center through promotion of high-quality patient centered care.
• Performs other duties as assigned.

Required Qualifications – Experience & Education

• Bachelor’s degree in nursing (RN)
• Current Montana nursing license
• Two years of experience with adult and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical.
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
• Care management experience preferred.
• Supervisory experience in a clinical setting preferred.
• Excellent assessment and triage skills.
• Excellent communication and interpersonal skills.
• Strong time management, priority setting, work delegation, and work organization skills.

Knowledge, Skills, & Abilities

PVHC Policies and Procedures

• Professional ethics, standards, practices, and responsibilities
• Knowledge of current practices in population health
• Ability to identify disparities and develop programs/intervention to help reduce them
• Disease specific standards of care
• Chronic disease self-management coaching techniques
• Health and welfare laws and ordinances
• Americans with Disabilities Act
• Community health and human service resources
• Public health quality assurance and quality improvement policies and programs
• Assessment techniques and practices for physical and mental health
• Understand and follow HIPAA regulations and practices
• Federal laws and standards for federally qualified health centers
• Organize resources according to prescribed standards
• Establish priorities, prepare reports and make presentations according to prescribed standards
• Understand and follow verbal and/or written policies, procedures, and instructions
• Operate computer systems and related software, including word processing, email, and spreadsheet programs. Ability to use common office machines
• Communicate effectively orally and in writing with respect to both patients and staff
• Establish and maintain effective working relationships with patients, fellow employees, supervisors, community service organization representatives and citizens Access and query electronic health records 
• Patient Centered Medical Home delivery system
• Practices techniques of training and mentorship
• Work in a team and delegate responsibilities and duties
• Set priorities, be organized, and be a self-starter
• Work independently
• Work toward a common goal
• Establish and maintain effective working relationships with individuals from diverse backgrounds

Special Requirements

Must have current Montana Nursing License

Must have current BLS certificate

Some travel may be required

Physical Demands

Duties are generally performed in a medical clinic environment where hazards and discomforts are controlled and modifiable. This position requires the ability to stand, bend at the waist, kneel, reach over the head, talk, hear, and see. Must be able to move or lift documents and materials weighing up to 30 pounds. Position requires frequent contact with clinic employees and clients, and occasional contact with community service agencies and citizens. Position may require occasional visits to other sites. 

What We Offer:

• Meaningful work serving underserved communities  
• Inclusive and team-oriented workplace  
• Competitive benefits package include:
• Health, dental, vision insurance
• Life insurance 
• 401k  
• Paid time off including PTO, sick leave, holidays, and floating holidays.