Registered Nurse - Population Health Charge Nurse
Partnership Health Center, Missoula, MT, United States
DEFINITION
Plans, organizes, and provides direct patient care and population-based care management services within a Federally Qualified Health Center (FQHC). Identifies and manages high-risk, rising-risk, and specialty populations; develops and monitors individualized care plans; supports preventive care outreach; and tracks clinical outcomes to support UDS reporting, quality improvement, and Value-Based Care initiatives. Works collaboratively with providers, care teams, and community partners to improve patient outcomes and advance health equity.
REPRESENTATIVE EXAMPLES OF WORK
Provides direct nursing care within scope of practice, including nurse triage, health assessments, clinical decision support, immunizations, injections, and point-of-care testing (e.g., glucose, A1c, INR, rapid tests).
Performs comprehensive and focused patient assessments, including physical, psychosocial, and social determinants of health; documents assessments, interventions, and outcomes accurately in the electronic medical record.
Delivers evidence-based patient education related to chronic disease management (including diabetes, hypertension, asthma, and COPD), medications, lifestyle modification, preventive care, and self-management strategies.
Identifies high-risk, rising-risk, and specialty populations using EMR data, registries, risk stratification tools, and quality reports; conducts care management assessments and enrolls eligible patients into population health and care management programs.
Develops, implements, and regularly updates individualized, patient-centered care plans in collaboration with patients, providers, and interdisciplinary care teams.
Coordinates care across primary care, behavioral health, specialty care, inpatient services, and community-based resources; supports care transitions and proactive follow-up to reduce avoidable utilization.
Supports population health outreach efforts focused on preventive care and care gap closure, including cancer screenings, immunizations, and chronic disease monitoring, utilizing evidence-based clinical guidelines.
Conducts phone, electronic, and in-person outreach to engage patients in recommended services; documents outreach activities and outcomes in the EMR.
Tracks, analyzes, and reports clinical and utilization data to support UDS reporting, payer quality metrics, and Value-Based Care programs; monitors patient outcomes and identifies gaps in care.
Participates in quality improvement initiatives, chart reviews, audits, and workflow optimization efforts to support compliance with FQHC requirements and regulatory standards.
Supports development, implementation, and ongoing administration of population health and care management programs; assists with staff education related to population health workflows and best practices.
Serves as a clinical liaison between patients, providers, care teams, and external partners; communicates professionally, compassionately, and clearly with diverse populations.
Maintains clinical competencies and adheres to nursing standards, infection control practices, organizational policies, and regulatory requirements.
OTHER DUTIES
Performs related duties as required or directed.
SUPERVISION RECEIVED
Works under the general direction of the Clinic Director or designee.
SUPERVISION EXERCISED
Provides functional guidance and clinical support to care team staff related to population health and care management workflows. Directly supervises population health staff.
WORKING RELATIONSHIPS
Works closely with medical providers, nursing staff, behavioral health, care coordinators, quality and data teams, hospital discharge planners, public health agencies, community-based organizations, and other specialty or social service providers involved in patient care.
REQUIRED KNOWLEDGE
Working knowledge of population health principles, care management models, chronic disease management, preventive care guidelines, and value-based care programs.
Working knowledge of UDS reporting requirements, quality metrics, and healthcare regulatory standards.
Working knowledge of HIPAA compliance, infection control practices, and Healthcare Professional Basic Life Support (BLS) guidelines.
REQUIRED SKILLS
Skill in clinical assessment, care coordination, patient education, and care planning.
Skill in use of electronic health records (including EPIC), registries, and reporting tools.
Skill in data analysis, quality improvement, and documentation.
REQUIRED ABILITIES
Ability to coordinate complex, patient-centered care plans and manage multiple priorities in a fast-paced environment.
Ability to analyze clinical and quality data and make recommendations to care teams.
Ability to communicate effectively, both verbally and in writing.
Ability to establish and maintain effective working relationships with diverse individuals and interdisciplinary teams.
Ability to provide culturally responsive care to underserved populations.
MINIMUM QUALIFICATIONS
EDUCATION
Requires a Bachelor’s degree in Nursing.
EXPERIENCE
Requires a minimum of three (3) years of nursing experience, preferably in primary care, population health, care management, or community health.
SPECIAL REQUIREMENTS
Requires current, unrestricted license to practice as a Registered Nurse in Montana.
Subject to passing a criminal background investigation that will require fingerprinting. May include pre-employment drug screening.
Requires a current Healthcare Professional BLS certification or the ability to obtain it within 90 days of hire.
Requires immunizations or proof of immunity to certain infectious diseases and a TB test.
New employees will be asked to volunteer vaccination status for required vaccines upon hire and will be offered assistance during hiring to receive necessary immunizations.
Employees who have not received the vaccines required for their positions or who are unwilling to voluntarily provide vaccination status for required vaccines will receive a reasonable accommodation where such accommodation does not require an undue hardship or endanger the health or safely of any person.
PHYSICAL/ENVIRONMENTAL DEMANDS
The work requires some physical exertion such as standing, walking, bending, and occasional lifting of up to 25 pounds. Requires manual dexterity to perform nursing skills such as giving injections and performing point-of-care testing. The employee may be exposed to communicable diseases. This job is primarily clinic-based and not eligible for remote work; work schedules may include evening and weekend hours, and travel to other satellite locations as needed.
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Plans, organizes, and provides direct patient care and population-based care management services within a Federally Qualified Health Center (FQHC). Identifies and manages high-risk, rising-risk, and specialty populations; develops and monitors individualized care plans; supports preventive care outreach; and tracks clinical outcomes to support UDS reporting, quality improvement, and Value-Based Care initiatives. Works collaboratively with providers, care teams, and community partners to improve patient outcomes and advance health equity.
REPRESENTATIVE EXAMPLES OF WORK
Provides direct nursing care within scope of practice, including nurse triage, health assessments, clinical decision support, immunizations, injections, and point-of-care testing (e.g., glucose, A1c, INR, rapid tests).
Performs comprehensive and focused patient assessments, including physical, psychosocial, and social determinants of health; documents assessments, interventions, and outcomes accurately in the electronic medical record.
Delivers evidence-based patient education related to chronic disease management (including diabetes, hypertension, asthma, and COPD), medications, lifestyle modification, preventive care, and self-management strategies.
Identifies high-risk, rising-risk, and specialty populations using EMR data, registries, risk stratification tools, and quality reports; conducts care management assessments and enrolls eligible patients into population health and care management programs.
Develops, implements, and regularly updates individualized, patient-centered care plans in collaboration with patients, providers, and interdisciplinary care teams.
Coordinates care across primary care, behavioral health, specialty care, inpatient services, and community-based resources; supports care transitions and proactive follow-up to reduce avoidable utilization.
Supports population health outreach efforts focused on preventive care and care gap closure, including cancer screenings, immunizations, and chronic disease monitoring, utilizing evidence-based clinical guidelines.
Conducts phone, electronic, and in-person outreach to engage patients in recommended services; documents outreach activities and outcomes in the EMR.
Tracks, analyzes, and reports clinical and utilization data to support UDS reporting, payer quality metrics, and Value-Based Care programs; monitors patient outcomes and identifies gaps in care.
Participates in quality improvement initiatives, chart reviews, audits, and workflow optimization efforts to support compliance with FQHC requirements and regulatory standards.
Supports development, implementation, and ongoing administration of population health and care management programs; assists with staff education related to population health workflows and best practices.
Serves as a clinical liaison between patients, providers, care teams, and external partners; communicates professionally, compassionately, and clearly with diverse populations.
Maintains clinical competencies and adheres to nursing standards, infection control practices, organizational policies, and regulatory requirements.
OTHER DUTIES
Performs related duties as required or directed.
SUPERVISION RECEIVED
Works under the general direction of the Clinic Director or designee.
SUPERVISION EXERCISED
Provides functional guidance and clinical support to care team staff related to population health and care management workflows. Directly supervises population health staff.
WORKING RELATIONSHIPS
Works closely with medical providers, nursing staff, behavioral health, care coordinators, quality and data teams, hospital discharge planners, public health agencies, community-based organizations, and other specialty or social service providers involved in patient care.
REQUIRED KNOWLEDGE
Working knowledge of population health principles, care management models, chronic disease management, preventive care guidelines, and value-based care programs.
Working knowledge of UDS reporting requirements, quality metrics, and healthcare regulatory standards.
Working knowledge of HIPAA compliance, infection control practices, and Healthcare Professional Basic Life Support (BLS) guidelines.
REQUIRED SKILLS
Skill in clinical assessment, care coordination, patient education, and care planning.
Skill in use of electronic health records (including EPIC), registries, and reporting tools.
Skill in data analysis, quality improvement, and documentation.
REQUIRED ABILITIES
Ability to coordinate complex, patient-centered care plans and manage multiple priorities in a fast-paced environment.
Ability to analyze clinical and quality data and make recommendations to care teams.
Ability to communicate effectively, both verbally and in writing.
Ability to establish and maintain effective working relationships with diverse individuals and interdisciplinary teams.
Ability to provide culturally responsive care to underserved populations.
MINIMUM QUALIFICATIONS
EDUCATION
Requires a Bachelor’s degree in Nursing.
EXPERIENCE
Requires a minimum of three (3) years of nursing experience, preferably in primary care, population health, care management, or community health.
SPECIAL REQUIREMENTS
Requires current, unrestricted license to practice as a Registered Nurse in Montana.
Subject to passing a criminal background investigation that will require fingerprinting. May include pre-employment drug screening.
Requires a current Healthcare Professional BLS certification or the ability to obtain it within 90 days of hire.
Requires immunizations or proof of immunity to certain infectious diseases and a TB test.
New employees will be asked to volunteer vaccination status for required vaccines upon hire and will be offered assistance during hiring to receive necessary immunizations.
Employees who have not received the vaccines required for their positions or who are unwilling to voluntarily provide vaccination status for required vaccines will receive a reasonable accommodation where such accommodation does not require an undue hardship or endanger the health or safely of any person.
PHYSICAL/ENVIRONMENTAL DEMANDS
The work requires some physical exertion such as standing, walking, bending, and occasional lifting of up to 25 pounds. Requires manual dexterity to perform nursing skills such as giving injections and performing point-of-care testing. The employee may be exposed to communicable diseases. This job is primarily clinic-based and not eligible for remote work; work schedules may include evening and weekend hours, and travel to other satellite locations as needed.
#J-18808-Ljbffr