Our Mission: To improve the health and well-being of the communities we serve demonstrating compassionate, patient-centered care.

Summary

The Care Management Nurse is responsible for overseeing and guiding several tasks to ensure that patients receive the best continuity of care throughout the entire Cozad Community Health System. The Population Health Education portion of the position is responsible for developing and implementing comprehensive health education programs aimed at promoting preventative care, chronic disease management, and community engagement in accordance with the philosophy, goals, and objectives of Cozad Community Health System.

Essential Duties and Responsibilities

This description intends to describe the general nature and level of work performed by employees assigned to this job. It is not intended to include all duties, responsibilities, and qualifications. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

· Identifies, monitors, and assists in closing care gaps related to preventive screenings, chronic disease management, annual wellness visits, immunizations, and other quality measures.

· Utilizes Population Health and ACO reporting tools to prioritize outreach efforts and improve quality performance metrics.

· Conducts patient outreach and follow-up activities to support completion of recommended services and improve health outcomes.

· Collaborates with providers, clinic staff, care teams, and community partners to coordinate services and remove barriers to care.

· Supports transitions of care activities including post-discharge follow-up, medication reconciliation coordination, and referral management.

· Assists in the implementation and monitoring of value-based care initiatives, quality improvement projects, and population health programs.

· Partners with Population Health leadership to improve performance in organizational focus areas including chronic disease management, preventive screenings, annual wellness visits, and other quality initiatives.

· Participates in multidisciplinary care management meetings to identify high-risk patients and develop strategies to improve patient outcomes and reduce avoidable utilization.

· Stays informed on Population Health trends and best practices, supporting both staff and patient education in partnership with medical staff. 

· Assists with coordination of patient care, education and transition support in discharge coordination. 

· Follows all HIPAA guidelines and promotes and ensures patient safety.

· Fulfills mission statement by performing job duties with a high level of customer service while contributing to a positive and professional environment.

· Special projects and other duties as assigned.

Education and/or Experience

Associates or Bachelor’s Degree in Nursing from an accredited College of Nursing. One year of full-time experience in rural healthcare preferred. Electronic Health Records experience required.

Licensure/Certification

Current Registered Nurse licensure in the State of Nebraska. Basic Life Support (CPR)

Valid Driver’s License

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit; use hands to fingers to handle or feel; and talk or hear. The employee is occasionally required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 35 pounds; must occasionally push, pull and assist with lifting up to 300 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Ability to operate a motor vehicle and complete errands based on business needs.

Work Environment

While performing the duties of this job, the employee regularly works in a hospital setting. The noise level in the work environment is usually moderate.

Equal Employment Opportunity

Cozad Community Health System is committed to hiring and developing the most qualified employees from the available workforce in the communities we serve.

Equal employment opportunity has been, and will continue to be, a fundamental principle at Cozad Community Health System, where employment is based upon personal capabilities and qualifications without discrimination and retaliation because of veteran status, uniformed service member status, race, color, national origin or ancestry, creed, religion, sex, sexual orientation, gender identity or expression, age, pregnancy (including childbirth, lactation, and related medical conditions), national origin or ancestry, physical or mental disability, genetic information (including characteristics and testing), or any other protected characteristic as established by applicable local, state, or federal law.