Health Equity - Nurse Case Manager - Population Health 148-2006

JOB SUMMARY:
The Population Health Nurse Case Manager supports Population Health Management (PHM) by assessing member needs, coordinating care, and promoting improved health outcomes. This role works with members, caregivers, providers, and interdisciplinary teams to develop individualized care plans, address barriers to care, and reduce avoidable utilization.

KEY RESPONSIBILITIES:

Identify and engage members with complex conditions, care gaps, or elevated health risks using referrals, assessments, and population health data.
Complete member assessments and develop individualized care plans within nursing scope of practice.
Provide ongoing outreach to monitor progress, address changing needs, and update care plans.
Coordinate medical, behavioral health, pharmacy, and community services to support member goals.
Support transitions of care through timely follow-up, discharge coordination, and connection to needed services.
Educate members and caregivers on chronic condition management, preventive care, and treatment adherence.
Address social needs and barriers involving transportation, affordability, access, and health literacy.
Participate in interdisciplinary care meetings and communicate care plans to members and appropriate providers.
Maintain timely documentation and support quality improvement, accreditation, and regulatory requirements.
Perform other job-related duties as required or assigned.

QUALIFICATIONS:

Knowledge of managed care, case management, chronic conditions, and community resources.
Strong clinical judgment, organizational, communication, and collaboration skills.
Ability to prioritize member needs and support member-centered care.
Proficiency with Microsoft Office applications and electronic care management systems.
Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

Graduation from an accredited School of Nursing.
Current, active, unrestricted Oklahoma RN License.
A minimum of four years of clinical nursing experience in an acute care setting.
Previous discharge planning or case management experience.
Certified Case Manager (CCM) certification preferred.