Chronic Care Management Nurse

We’re different. In a good way. In communities like ours, co-workers and patients are our friends and neighbors. Sometimes they are family. And we take care of each other like family. If you’re tired of the typical workplace grind, we have something very different in store for you. Reasonable hours, a devoted team, a commitment to improvement, and believing in the value of every person – whether employee or patient – are just a few of the qualities for which we’re known.We’re a human potential company. Join us and experience the difference of the Desert Sage Way. We can’t wait to meet you.

Desert Sage Health Centers believes in patient-focused care delivered through a caring team of competent and caring health care professionals. As a Patient Centered Medical Home (PCMH), Desert Sage Health Centers prides itself in the quality of care it delivers to more than 7,800 annual patients at three health center site locations. Our integrated system emphasizes prevention, healthy living and is designed to reduce health care disparities and avoid unnecessary trips to emergency rooms or other more costly forms of care.

We are looking for an outgoing, compassionate, and hard working individual to join our dental team! If Desert Sage Health Centers and the Chronic Care Management Nurse position seems like a good fit, then please take a few moments to submit your application!

Primary Duties And Responsbiliities

Program Development

• Ensure compliance with NCQA PCMH concepts, specifically around care coordination, care plans, transitions of care post-discharge and care management
• Oversee, and maintain a CMS-billable Chronic Care Management program by maintaining and updating workflows, documenting processes, educating staff, working with Population Health Manager and vendor to ensure quality service and a financially sustainable program
• Develop, monitor, and report metrics throughout the health center to identify patient progress and overall success of Care Management and Remote Patient Monitoring Programs
• Maximize team-based care by developing strong working relationships with specialty providers and the DSHC care teams
• Assist to develop and document systems for risk stratification, registry creation and maintenance, closed-loop care, case management documentation, and standard workflows as the organization transitions to value-base care
• Serves as a clinical leader in the health center for improving care, quality measures, enhancing integration of care team operations, and facilitating quality improvement efforts through teamwork with Director of Quality & Development, Medical Clinic Manager, Chief Clinical Officer, Population Health Manager, Assistant Medical Director, and other key team members
• Assist with Quality and Risk Management Program activities by providing guidance and education to clinical staff on topics such as infection control, clinical risk management, care planning, etc
• Provide clinical expertise and guidance for incidents, chart reviews, etc
  
  

Clinical Care Management

• Serve as the organization’s key point of contact for initiating or delegating clinical response to patient needs identified through the Chronic Care Management Program, Remote Patient Monitoring, and similar services for patients
• Work with care teams and leadership to develop a prioritization list for building and managing care management panels
• Promotes clear communication among the care team by ensuring documentation, continuity, maintenance, and thoroughness of patient care plans
• Facilitates patient medication management based upon standing orders and protocols; includes conducting reconciliation for polypharmacy patients to ensure medication safety and patient understanding of medication use
• Facilitates health and disease patient education during clinic visits, virtually via telehealth encounters, telephone calls, and in the community during key Outreach activities
• Supports patient self-management of disease and behavior modification interventions
• Documents Remote Patient and Care management activities in the EMR to ensure proper documentation, maximum revenue capture, and relay important updates to primary care providers. Continue to monitor and optimize mechanisms to reliably identify and track patients discharged from inpatient care; ensure patients discharged from the hospital are seen within 7-14 days of discharge
• Complete post-discharge calls to patients within 72 hours of discharge according to standard scripting (medication review, upcoming appointments, plan of care as outlined by hospital, etc.)
• Build a strong relationship with the hospital, and serve as the patient care liaison to ensure DSHC is able to receive notification and discharge information from the hospital(s) when patients are discharged and/or need follow-up appointments, leveraging health information exchange whenever possible
• Provides guidance on priority areas for outreach to ensure high-risk patients receive appropriate screenings and services
• Works with internal programs such as Outreach, Behavioral Health, Dental, etc. to coordinate outreach, education, and appropriate services for care managed patients
• Connect patient to internal and external resources if needed, for example: Medication Assistance Programs, 340B, CHW, BH walk-in clinic, Women’s Health Check, Mammo Bus. Communicates closely with referral coordinators and updates Pop Health team regularly
• Other duties as assigned based on the needs of the health center
  
  

Minimum Qualifications

• Must hold current RN License in Idaho
• BSN degree strongly preferred
• Must hold current BLS card (healthcare provider)
• 3-5 years of direct experience providing case management to diverse patient populations
• Demonstrated understanding of best practices in chronic disease case management and population health
• Demonstrated ability to aggregate, analyze, and act upon clinical data
• Demonstrated experience with running quality improvement projects and process improvements preferred
• Bilingual English/Spanish strongly preferred
  
  

Benefits include paid holidays, vacation, health and dental insurance. Salary is DOE.

If you are self motivated, compassionate and ready to give back to your community, and have the necessary training, come join our team!

Desert Sage Health Centers provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

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