PCHH RN Care Manager

Essential Job Responsibilities

• Direct relationships with patients and coordination with primary care team, specialty care teams, and inpatient facilities.
• Develop care plans, monitor medication adherence and reconciliation, identify and address high utilizers.
• Utilize critical thinking skills to interpret and act in accordance with Four Rivers Community Health Center Mission, Vision, and Values in a variety of complex situations.
• Demonstrate understanding of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and comply with patient information safeguard guidelines to protect patient information.
• Demonstrate expert communication skills with patients, Four Rivers Community Health Center administrative and multidisciplinary team members, and community partners.
• Use evidence-based guidelines, literature, program assistance letters (PALs), official manuals and regulations, and appropriate nursing assessments to assist in the coordination of care of individual patients and management of population health to include but not limited to social determinants of health (SDOH), chronic disease management, ER utilization and hospital admissions.
• Be proficient at utilizing the EHR, DRVS, Cyber Access, eMOMED, Health Information Exchange (HIE) connected portals, and other applicable data sources to obtain patient information for coordination of care and evaluation of effectiveness of all population health related programs.
• Utilize afore listed data repositories (Item 7.) to extract, analyze and interpret data to evaluate and address care gaps and affect positive patient outcomes for population health programs.
• Participate and lead quality improvement initiatives associated with population health, quality measures for various organizations and required compliance (MPCA, MCO's, HEDIS, UDS).
• Provide the highest level of customer service striving to provide a patient experience that is keeping with Four Rivers Community Health Center core values and as outlined by AIDET.

Qualifications

• Education: Degree resulting in qualification to sit for the NCLEX to become a Registered Nurse; BSN or MSN preferred.
• Experience: Minimum three years of experience as a registered nurse and one year of case management, care coordination, or program management preferred.