Registered Nurse - Nurse Care Manager - East Side Clinic

About the role

As a Nurse Care Manager at PHC, you will implement risk stratification strategies to identify patient populations requiring higher-level care management, disease/chronic condition management, and psychosocial support. You will provide holistic care management and coordination for patients with complex needs, working as part of an interdisciplinary care team to meet the changing needs of patients. This position typically works at PHC East Side Clinic in Des Moines and is scheduled Monday - Friday 8 AM - 5 PM, with occasional travel to other sites for meetings or coverage at other PHC clinics in Ames, Des Moines, and Marshalltown. Mileage reimbursement and/or an out-of-town travel bonus may apply.

Responsibilities

• Utilize interventions for population health management to maximize health and recall opportunities for care-managed patients, those in Accountable Care Organization contracts, or warm hand-offs from PHC providers with complex needs.
• Address the medical, psychosocial, health risk, prevention, wellness, and education needs of patients and/or families.
• Utilize the RN-led Visit Model, including nursing assessment, diagnosis, planning, implementation, and evaluation of nursing care plans.
• Provide care management, care coordination, chronic disease management, preventive screening, and education for patients and/or families.
• Support PHC Way initiatives, including pre-visit planning, post-visit follow-up, and care coordination.
• Execute the strategy for planned visits, including appropriate health prevention and screening activities.
• Participate in Accountable Care Organization activities such as value-based care, shared savings initiatives, Medicare Annual Wellness Visits, Medicaid recall care coordination, and chronic care/disease management.
• Document patient care accurately and timely in the electronic health record.
• Assist with panel assignments and workload to balance the complexity and continuity of care needs.
• Perform nursing triage of acute medical issues for clinic patients as needed, referring or monitoring appropriately.
• Utilize data systems and reporting to monitor population health management patient outcomes and identify gaps in care.
• Participate in grant-related clinical initiatives.

Requirements

• Completion of an accredited nursing program accepted by the Iowa Board of Nursing for licensure.
• Verbal and written communication skills, including the ability to provide effective education to others.
• Interpersonal skills and the ability to maintain professional relationships with a wide variety of people.
• Ability to work collaboratively and autonomously.
• Commitment to service excellence.
• Self-motivated and takes initiative.
• Active listening skills and a willingness to take direction.
• Problem-solving skills with the ability to apply critical thinking and assessment within a nursing framework.
• Time management skills with the ability to efficiently move between tasks.
• Consistently meets the department work schedule as assigned.
• Detail-oriented.
• Proficiency using electronic health records, Microsoft Office applications, and internet-based applications.
• Adheres to patient confidentiality standards.
• Ability to consistently meet care manager measures and acceptable performance standards.

Qualifications

• Current RN license recognized by the State of Iowa.
• Current Basic Life Support (BLS) for Healthcare Providers.
• Current Mandatory Reporter Training: Child Abuse and Dependent Adult Abuse recognized by the State of Iowa (must be obtained within the Introductory Period if not current).

Preferred:

• Bachelor of Science in Nursing.
• Experience in a community health center or public health organization.
• Experience with population health, care management/coordination, the Chronic Care Model, health registry systems, or community resources.
• Spanish language skills, written and verbal.

Schedule

Monday - Friday, 8 AM - 5 PM, with occasional travel to other sites or coverage at other PHC clinics in Ames, Des Moines, and Marshalltown.

Benefits

• Generous PTO accrual.
• Eight paid holidays.
• License/certification fee reimbursement (for positions requiring clinical licensure or certification).
• Paid time off for continuing education and continuing education reimbursement (for positions requiring clinical licensure or certification).
• Tuition reimbursement program.
• 401k with company match.
• Medical, dental, and vision insurance.
• Life and disability insurance.
• Flexible spending and health savings accounts.
• Supplemental accident and critical illness insurance.
• Discounted pet insurance.
• PHC Pride rewards program.