What We Are Looking For

The Population Health Care Manager (RN) is responsible for improving health outcomes for a large population of patients with diabetes, hypertension, and other chronic conditions within an outpatient primary care environment. Through primarily telephonic and campaign-based outreach, the RN delivers proactive assessment, education, care coordination, and clinical intervention.

The role leverages data analytics, risk stratification, and evidence-based guidelines to identify care gaps and prioritize services. Working in close partnership with providers and interdisciplinary teams, the RN supports continuity of care, referral management, and successful transitions across settings. This position is accountable for contributing to organizational performance on quality measures, including UDS and value-based benchmarks. The Population Health Care Manager also provides triage and cross coverage support to maintain patient access and operational efficiency.

Schedule: 5 days per week, 8 hours per day, Mon-Fri 7:30am-4pm 30min Lunch|Location: SBC Clinic, San Bernardino, CA

ESSENTIAL FUNCTIONS AND DELIVERABLES

• Manage assigned chronic disease panel (diabetes, hypertension, etc.) by developing, implementing, and continuously adjusting individualized care plans to improve clinical outcomes.
• Conduct proactive telephonic and campaign-based outreach to assess patient needs, address care gaps, and ensure timely completion of labs, screenings, and follow-up care.
• Provide clinical education and behavior-change coaching to support medication adherence, self-management, and lifestyle modification using evidence-based practices.
• Leverage data analytics and risk stratification tools to identify high-risk patients, prioritize outreach, and monitor performance against quality measures (e.g., UDS, value-based metrics).
• Coordinate care across interdisciplinary teams, including providers, care management, pharmacy, and community resources, to ensure continuity and comprehensive patient support.
• Facilitate referrals and transitions of care, including post-hospital or ED follow-up, to reduce gaps in care and prevent avoidable utilization.
• Participate in triage and cross-coverage activities to support patient access, respond to clinical needs, and maintain efficient departmental operations.

QUALIFICATIONS:

• Education: Bachelor's degree in Nursing preferred.
• Licensure/Certification: Current and unrestricted California Registered Nursing License, Basic Life Support (BLS) and current CPR certification required. As a requirement of this
  position, you must receive EPIC certification for the module you have been hired into. Certified Diabetes Care and Education Specialist (CDCES), Certified Case Manager
  (CCM) or Accredited Case Manager (ACM) is preferred.
• Experience: Minimum of three (3) years of clinical nursing experience at the RN level in ambulatory, primary care, or chronic disease management is required. Previous experience
  working in a FQHC or community health setting with a background in Care Management, Population Health, or Chronic Disease Management. Experiencing working with a
  diverse and underserved population. Previous experience working with UDS/HEDIS measures and patient registries within a performance driven environment is preferred.
• Essential Technical/Motor Skills: Computer competency; Able to read; write legibly; speak in English with professional quality; use computer, printer, and software programs
  necessary to the position.
• Interpersonal Skills: Professional and strong communication skills in difficult situations. Ability to descalate concerns. Telephone etiquette required. Ability to translate medical
  information. Effective communication. Team oriented.
• Essential Mental Abilities: Work independently and in teams; Ability to analyze data and create reports based on data.
• Work Eligibility: Must be legally authorized to work in the United States on a full-time basis. Must not now or in the future require sponsorship for employment visas.

Full Benefits Package

Industry Leading PTO Accrual (accrued per pay period) | Sick Leave | Paid Holidays | Paid Jury Duty, Bereavement | SAC Health Covers approximately 85% of Team Member health premium costs (may vary w/benefit plan selection) | Retirement - up to 8% employer contribution | Continuing Education and Learning Benefits | Annual Mission Trip and much more!