Population Health

Full Time Exempt 

40 hours/week

8a-430p

Hybrid Schedule 

Summary:

The Care Management Nurse Program Coordinator, under the direction of the department Supervisor, is responsible for the comprehensive coordination, delivery, and evaluation of care management services across the continuum of care for specific subpopulations of children/youth and their families. This role integrates complex care management, care coordination, programmatic oversight, and interdisciplinary collaboration to address medical, psychosocial, behavioral, educational, and resource-related needs. The Program Coordinator serves as a clinical leader, subject matter expert, and change agent to advance care delivery models, quality, patient experience and ensure high-quality, family-centered care while closing preventive care gaps and improving outcomes for relevant populations.

Responsibilities:

1. Assessment:

· Conducts comprehensive assessments of pediatric and young adult patients and families with complex medical, behavioral, developmental, and social needs using a trauma-informed, family-centered approach.
· Identifies high-risk populations using stratification tools, referral sources, and program eligibility criteria.
· Assesses caregiver capacity, health literacy, barriers to care, and social drivers of health to inform care planning and program interventions.

 2. Nursing Diagnosis and Outcomes Identification:

· Analyzes assessment data to identify priority care management needs and risk factors impacting individual and population health outcomes.
· Establishes measurable, patient- and family-centered goals in collaboration with patients, caregivers, and interdisciplinary teams.
· Defines short- and long-term outcomes aligned with quality metrics, population health initiatives, and organizational priorities.

3. Planning:

· Develops and oversees individualized and population-based care plans addressing physical, behavioral, and psychosocial health needs while incorporating family preferences and cultural considerations.
· Collaborates with interprofessional colleagues and community partners to design coordinated, whole-person care strategies across the continuum of care.
· Ensures care plans and workflows meet documentation, timeliness, and patient engagement standards.

4. Implementation:

· Coordinates care across providers and settings including primary care, specialty care, hospitals, schools, home health, and community agencies to ensure continuity of care.
· Provides clinical leadership, consultation, and support to nursing staff and interdisciplinary team members involved in care management and care coordination.
· Delivers education and coaching to patients, caregivers, and care teams related to disease management, self-care strategies, and community resources.
· Participates in interdisciplinary care conferences to support integrated care delivery and shared accountability for outcomes.

5. Evaluation:

· Monitors patient, family, and population outcomes relative to established goals and program benchmarks.
· Evaluates effectiveness of interventions in improving quality of care, patient experience, and population health outcomes.
· Uses outcome data to guide care plan revisions, program enhancements, and quality improvement initiatives.

6. Documentation and Compliance:

· Documents all nursing interventions, assessments, and outcomes in accordance with organizational policies, regulatory standards (i.e., NCQA CCM, The Joint Commission, etc.).
· Ensure continuous compliance with NCQA CCM standards through ongoing review, audit readiness, and quality improvement activities.
· Maintains confidentiality and adheres to ethical standards American Nurses Association (ANA) Code of Ethics for Nurses and institutional policies.

7. Program Coordination & Leadership:

· Serves as a clinical leader and subject matter expert for care management, complex disease management, and care coordination practices.
· Identifies educational needs of nursing and multidisciplinary staff and supports training and competency development.
· Facilitates interdisciplinary collaboration to advance care delivery models and improve quality, patient experience, and population outcomes.

8. Other duties as required.

Other information:

Technical Expertise

Full Time

FTE: 1.000000

Status: Fixed Hybrid