Nurse Case Manager-Population Health

Job Description

Job Description

Wages negotiable based on experience.

Well Care Community Health, a Federally Qualified Health Center, is a mission-driven organization that provides access to high-quality health care, including dental and behavioral health, to underserved members of our communities.

Principal Function:  The Case Manager is a clinic-based member of the population health team who supports clinical case management of patients with complex chronic, behavioral health, and post-acute needs. Working under the direction of the Population Health Nurse and in close coordination with providers and other staff, the Case Manager maintains individualized care plans, supports Remote Patient Monitoring (RPM) enrollment and day-to-day workflows, coordinates transitions and follow-up, and helps the care team carry out the clinical plan across settings. When social determinants of health or community-resource barriers are identified, the Case Manager partners with the CHW, who leads community navigation and regional-partner linkage, while the Case Manager remains focused on continuity of the clinical care plan and communication among care-team members.

Essential Duties and Responsibilities:  Duties include, but are not limited to:

1. Review referrals, risk information, care-team recommendations, and available records to identify clinical coordination needs; promptly route clinical assessment or decision-making questions to the Population Health Nurse or provider.
2. Develop, maintain, and update individualized case-management care plans based on goals and instructions established by the licensed care team, and track progress, responsible staff, deadlines, and unresolved needs.
3. Coordinate medical appointments, specialty consultations, diagnostic testing, laboratory follow-up, medication-related follow-up, and other services required to carry out the clinical care plan.
4. Support transitions after emergency department visits, hospitalization, or other changes in care setting by obtaining available information, arranging timely follow-up, and coordinating medication reconciliation or clinical review by licensed staff.
5. Support RPM enrollment, consent workflow, device assignment, patient onboarding, monitoring schedules, and education using approved materials and procedures.
6. Monitor RPM dashboards, readings, and alerts according to written protocols, document actions, and promptly route abnormal data or clinical concerns to the Population Health Nurse or provider. The Case Manager does not independently interpret clinical data or make treatment decisions unless appropriately licensed and authorized.
7. Track missing RPM readings, adherence, device or connectivity problems, and patient engagement; coordinate resolution with the patient, CHW, Informatics/IT, vendor, and clinical team as appropriate.
8. Reinforce approved disease self-management, medication adherence, and care-plan instructions; refer questions requiring clinical judgment to licensed staff.
9. Coordinate communication and action among the Population Health Nurse, providers, pharmacy, behavioral health, laboratory, radiology, Street Medicine, transportation, medication-access, and other involved staff.
10. Maintain closed-loop clinical referrals by tracking appointments, reports, results, outstanding orders, and recommended follow-up through completion or documented disposition.
11. Identify transportation, food, housing, insurance, financial, digital access, employment, education, or other barriers that interfere with the clinical plan and make a warm handoff to the CHW for community navigation and regional-partner support.
12. Coordinate care with hospitals, specialists, behavioral health providers, home health, public health, and other outside clinical organizations while maintaining timely communication with the WCCH care team.
13. Educate patients and families about the care-coordination process, upcoming clinical steps, available supports, and how to contact the team when needs change.
14. Maintain accurate, timely, and confidential documentation of care plans, contact, RPM activity, referrals, transitions, actions, outcomes, and escalations in the EHR and other approved systems.
15. Monitor caseload status and patient progress; participate in interdisciplinary huddles, identify patients needing higher-level review, and escalate clinical deterioration, safety concerns, or unresolved barriers promptly.
16. Participate in staff meetings, quality-improvement activities, workflow development training, and grant-supported outcome tracking as required; comply with HIPAA, OSHA, organizational policy, and applicable law.

Supervisory Responsibilities:  This job has no supervisory responsibilities.

Education and/or Experience:  Associate degree or higher in nursing, social work, human services, healthcare administration, or a related field is preferred. A high school diploma or GED plus at least three years of directly relevant healthcare case-management or clinical care-coordination experience may be considered. Experience with chronic-disease management, transitions of care, RPM, EHR-supported care plans, and interdisciplinary healthcare teams is strongly preferred.

Work-Life Balance:

Well Care understands our employees’ commitment to community and family and offers the following benefits:

12 paid holidays

Up to 20 other paid days off

Medical, Dental and Vision insurance

Long-term disability

Life Insurance

401K

Reimbursement for licensing or certification

 

Current Office hours Monday through Friday 8 a.m. to 5 p.m.

This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.