RN - Population Health Care Manager

Salary depends on experience
Posted on 09/28/17
Less than 5 years experience
Patient Care
Salary depends on experience
Posted on 09/28/17

Drives the overall successful multidisciplinary approach to management and coordination of care delivered in a patient centric approach within the patient-centered medical home (PCMH) care delivery model. This is achieved by collaboratively working with patients, physicians, practice teams, and the health plan to integrate the key features of the PCMH and the Triple Aim concepts, as defined when developing and managing members individualized care plans.  The Ambulatory Care Manager engages the member in an active role in the management of his/her disease or medical condition, as defined, and promotes member education and self-management skills.  Assists in the identification of appropriate providers, facilities, and community resources in an effort to improve or maintain the member's social, emotional, functional, and physical health status.  Engages the member to assess and improve the status of current medical, environmental, and social needs.  The focus of the Ambulatory Care Manager is to promote whole person health and development of self-management skills. Support the member with emphasis on providing education, disease management, and establishment of routine contact with the primary care physician/provider and facilitate specialist referrals and other care as appropriate per physician orders.  Additionally works to coordinate disease registry activities, performance reporting, and regular meetings with all stakeholders regarding success or improvements within the medical home. The Ambulatory  Care Manager has a collaborative relationship with the multidisciplinary team and the ISHN care management staff.
The role of the ambulatory patient care manager is to assist the multidisciplinary team and educate them on how to effectively collaborate with and appropriately utilize imbedded care mangers as a valuable member of the multidisciplinary care team.

Job Duties & Responsibilities
*    Leads and coordinates the multidisciplinary team in order to ensure coordinated patient centered care is provided consistent with the IHI Triple Aim goals of improved outcomes, better consumer experience and affordability.
*    Responsible for carrying out key functions related to the success of the PCMH program including member outreach, PCMH reporting, performance measurement, and acting as key liaison between patient, clinical practice sites and Integrated Health Solutions Network.
*    Analyzes the member's complex clinical trends, and outcomes data including clinical/claims history, outpatient treatments, inpatient treatments, emergency room visits, medications, medical benefits from electronic Medical Records (EMR), chart reviews, or other information, to assist in the monitoring and facilitation of adherence to prescribed care plans.
*    Performs comprehensive clinical, disease specific and psychosocial assessments necessary to develop and implement integrated multidisciplinary plans of care.
*    Identifies from collaboration with the member opportunities for optimizing care and organizes clinical services with specialists and other providers to drive a successful outcome.
*    Aggressively  implements quality and cost alternatives for medications, DME, and supplies, referral and coordination to network specialists, and facilitated engagement with appropriate resources, as developed in the plan of care.
*    Coordinates and collaboratively manages care with internal and external team members to the clinical practice site, complex plan based case manager or health coach, for ongoing condition management or wellness education and support.
*    Uses motivational interviewing to enhance member understanding and healthy behavior driven by  the multidisciplinary treatment plan, including but not limited to, prescriptions, refills, medical supplies, referrals, authorization of services, and when to seek care.
*    Identifies and prioritizes individual needs that builds on establishing and developing rapport and trust that drives positive, improved self-directed wellness and management.
*    Assesses the behavior, social, cognitive, and support systems that impact the member and/or family to further assess social, emotional, functional and physical health status in achieving the highest level of physical and mental health
*    Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows all HIPAA guidelines and regulations.
*    Assists the member in navigating through  complex education and goals,  to execute the overall plan of care of a well to chronic patient; with focus on the maintenance and promotion of preventive screening, lifestyle coaching, and on-going follow-up care.

*    As part of the comprehensive treatment plan promotes education by supplying information materials, directing the member to the telephonic information library, approved websites or community resources, and/or services such as Disease Management or Case Management according to the member's contract.
*    Analyzes data and develops reports from generated PCMH and ISHN  Quality Improvement Program data that targets appropriate care opportunities
*    Drives the development of treatment protocols  in routine, cross-functional ISHN teams to review metrics and recommend quality improvements.

MSHA expects that every team member will role model Patient-Centered Care behaviors and be guided by MSHA's Values and the Principles of Patient-Centered Care. Every member of MSHA's leadership team is accountable for coaching and monitoring reporting team members to ensure that the standards and initiatives of Patient-Centered Care are a living reality in their work units / Departments.

It is vital that an individual in this position be capable of good communication skills. It is of the utmost importance that written communication is legible.

MSHA expects all team members to support the VOS initiative by demonstrating awareness of the VOS system and effectively applying it to his/her work.

Job duties of this position may require access to protected patient information (PHI). The team member will be accountable for appropriate use of the record and compliance with all confidentiality and security policy and procedures related to use, access, and disclosure of PHI.

RN can verbalize that the RN is responsible for all of the LPN's patients and therefore must ensure reporting from the LPN happens in a timely, appropriate and complete manner.


The Population Health Care Manager reports directly to the VP, Clinical Integration AnewCare Collaborative.


*    RN, bachelors prepared with active license in the state of TN or holding a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law required
*    Case management certification within 18months of hire
*    Advanced degree in nursing, population health management or healthcare related.
*    Current certification in case management
*    A minimum of 3 years varied case management clinical experience in an  ambulatory setting  
*    3-5 years' experience in direct patient care in a clinical setting
*    Must be PC literate with basic knowledge of Windows & Microsoft Office
*    Disease management experience

*    Preferred Case Management/Utilization Management or Disease Management Certification
*    Proficiency with Motivational Interviewing and/or other behavioral change techniques
*    Ability to build rapport and engage members in effective dialogue related to their treatment plan
*    Basic skills in project planning and execution
*    Understanding of data reporting and analysis for quality or performance improvement
*    Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions
*    Exceptional level of critical thinking, analytical and creative problem solving skills required
*    Exceptional level of independence, organization, and interpersonal skills required
*    Proficient with team-building processes and participation in cross-functional teams

Not the right job?
Join Ladders to find it.
With a free Ladders account, you can find the best jobs for you and be found by over 20,0000 recruiters.