Manager works collaboratively with all (10) OHSU Primary Care Departments and will over time begin to work with the PC Care Management teams at Tuality and Adventist. All practices are certified patient centered medical homes who offer team-based care to patients of all ages. Practice are quite varied in patients and communities served from rural health center to federally qualified health center to urban neighborhood locations. In total, the practice care for in excess of 100,000 covered lives. Care Management teams includes nurses, pharmDs, behaviorist, and a few community health workers.
1) Develop strategic plan for expanding the care management role and functions across Primary care: engaged with Population Health and IP Care Management teams in doing so.
2) Work with Operational Leaders to further develop the Care manager roles in Primary Care. Develop outcomes measures in collaboration with Chief Primary Care and Population Health Officer and Director, Population Health; measure and work to make improvements over time. Serve as an advocate for inter-professional teams who perform care management functions.
3) Population Health/Value Based Care: work on standard programs aimed to improve health outcomes and reduce poor use of hospital and ED resources. Create clinical collaboratives and develop best practices around care management for high risk and rising risk patients. Works closely with the new Integrated Delivery System (IDS) to maximize care coordination impacts and reduce/avoid redundancies.
4) Human Resources: work with care managers to create and execute professional development plans; carry out "grow" conversations with all PC Care Mangers. Mentor and coach PC Care Management team members.
5) Process Improvement: Identifies local and national trends in "best practice" in care management, care coordination. Leads PC process improvement initiatives in Care Management. Uses evidence and measurement tools to support innovations and program improvements.
Master's degree in Nursing
Minimum of (5) years experience as a registered nurse in an ambulatory setting
(2) years recent experience in care management/leadership
Professional certification in nursing leadership within (3) years of assuming manager role.
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