RN Nurse Care Manager - East Side Clinic

About the role

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 those patients with complex needs. You will work as part of an interdisciplinary care team to meet the changing needs of our patients.

Responsibilities

• Utilizes Interventions for Population Health Management to maximize the health and recall opportunities for patients who are care-managed, part of the Accountable Care Organization contracts, or warm hand-offs from PHC providers with complex needs.
• Addresses the medical, psychosocial, health risk, prevention, wellness, and education needs of the patient and/or family.
• Utilizes the RN-led Visit Model, including nursing assessment, diagnosis, planning, implementing, and evaluation of nursing care plans.
• Provides care management, care coordination, chronic disease and preventive screening and education for patients and/or families.
• Supports PHC Way initiatives and actively assists in pre-visit planning, post-visit follow-up, and care coordination.
• Executes the strategy for planned visits, including appropriate health prevention and screening activities.
• Participates in Accountable Care Organization activities such as value-based care and shared savings initiatives, completes Medicare Annual Wellness Visits and Medicaid recall care coordination, and provides chronic care, disease management, and complex care management.
• Documents patient care accurately and timely in the electronic health record.
• Affords assistance with panel assignments and workload, supports teams to balance the complexity and continuity of care needs of patients and the care teams.
• Performs nursing triage of acute medical issues for clinic patients as needed, refers or monitors appropriately.
• Utilizes data systems and reporting to monitor population health management patient outcomes and identify gaps in care.
• Participates in grant-related clinical initiatives.

Qualifications

• Required 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.
• Able to consistently meet care manager measures and acceptable performance standards.
• Licenses & Certifications: 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.

Skills

• Knowledge of population health management.
• Experience with care management/coordination.
• Experience with the Chronic Care Model.
• Experience with health registry systems.
• Experience with community resources.

Benefits

We Take Care of Our People In addition to base pay, PHC offers a comprehensive benefits package, including:

• Generous PTO accrual
• Eight paid holidays
• License/certification fee reimbursement
• Paid time off for continuing education & continuing education reimbursement
• Tuition reimbursement program
• 401k with company match
• MEDICAL INSURANCE
• DENTAL INSURANCE
• VISION INSURANCE
• LIFE & DISABILITY INSURANCE
• Flexible spending & health savings accounts
• Supplemental accident & critical illness insurance
• Discounted pet insurance
• PHC Pride rewards program

Grow Your Career with PHC

We take pride in offering development and growth opportunities to our team. Some of our training opportunities include Emerging Leaders, Dental Assitant Trainee Program, & Medical Assistant Trainee Program. In the last year, over 30% of our open positions were filled through promotions or transfers.

Join the PHC Community

Visit https://phciowa.org/careers for a summary of PHC’s benefits.