Population Health Manager (RN)

You belong here! At Family Health West, you’re more than an employee, you’re family. When you enter our facility, you know it’s Family Health West because, well, the color speaks for itself. You’ll be part of a team that strives to bring color to care in a vibrant environment by creating fun, effective treatment programs helping to empower and inspire our patients while providing the tools and care they need to achieve their wellness goals. When we say you’ll do what you love, we mean it! Welcomed by open arms and warm smiles, you’ll join a team that encourages professional growth. We are sure to put on our listening ears when you share new ideas and approaches to care because that’s what got us to the top! You’ll wear your badge proudly, knowing that you contribute each day, to providing care that is unmatched, in western Colorado. So, what are you waiting for?! Fill out the application now, and when you hit send do a little happy dance knowing that you just made our day. If it still sounds too good to be true, come see for yourself. Call us to schedule a tour and meet your new best friends! About Family Health West Our roots go deep -- founded by the community in 1946, it’s no wonder our hospital feels like coming home. We were built from the ground up with the hands of our own community, a labor of dedication and hope by our people, for our people, for the future. At Family Health West we go beyond what corporate hospitals deliver, we’ve created a culture of prosperity where warmth, passion, and care flourishes. As we focus on continually improving outcomes for patients, our network of healthcare providers includes a 25-bed critical access hospital, one of the largest rehab providers in western Colorado, outpatient surgical services, specialty clinics, emergency services, skilled nursing, and assisted living facilities. Nestled at the base of the Colorado National Monument, Family Health West has an outdoor paradise at your back door. The community culture is fitting for outdoor lovers, bikers, hikers, or those just simply soaking in the panoramic views. Essential Functions * Attend and actively participate in all Family Health West population health related trainings and meetings including advanced health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on-one meetings, as needed * Reliable and punctual attendance is essential; expected to be at job as scheduled each scheduled day.

• Communicate necessary information to others as appropriate.
• Works collaboratively with the FHW team to develop a process to track Annual

Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the provider; post reminders to ensure that all comorbidities are discussed and documented during AWV. * Establish competencies related to AWV screenings such as PHQ-9, TUG and Mini-Cog and assists FHW to train care team to perform these screenings. * Establish counseling services/resources within the practice to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety and advanced care planning. * Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases; determine frequency for provider visit and Chronic Care Management (CCM) encounters; maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact. * In collaboration with the primary care providers, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to the care plan and progress toward goals and facilitate changes as needed. * Participate in daily huddles with primary care provider and care team; identify scheduling opportunities, special needs for patients with appointments that day, patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments requiring rescheduling; ensure sharing of positive patient stories or compliments involving care team efforts. * Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/visits, and CCM encounters. * Must have the ability to collaborate as a group on projects as well as work autonomously. * Collaborate with practice leaders to establish a method for assigning patients into a panel listing by provider that is routinely utilized for scheduling purposes; utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers. Education: Education: Bachelor’s degree in Nursing, or Associates Degree in Nursing Licenses: Registered Nurse required Certifications: BLS required, Quality Improvement Certification preferred. Experience: Three (3) years of preferred related healthcare experience in population health, or in acute case setting, ambulatory care, home health, or physician practice. Wage range: The wage for this position starts at $37.35 and goes up based on experience. Opening Info: Open until filled. Immunizations required for employment Benefits FHW offers a full benefits package including:

FOR ALL EMPLOYEES:

Employee Assistance Program 403 (B) with 4% match from FHW and zero day vesting schedule FOR FULL TIME EMPLOYEES WORKING AT LEAST 30 HOURS A WEEK Medical Plan Options: I. PPO plan with copay/coinsurance and lower deductible II. High Deductible Health Plan with the option for a Health Savings Account. III. Telemedicine includes in both plan options. Dental Vision Life Insurance/ Accidental Death and Dismemberment Insurance Disability Insurance with a Short and Long Term Option. Critical Illness and Accident Plans Cafeteria Options: Health Reimbursement/ Flex Savings A host of other options to include: Pet Insurance, Identity Protection, Travel protection.