population health nurse

Trillium Health Resources

<div><div><b>Pay Plan Title: </b>RN</div><div><b>
Working Title: </b>Population Health Nurse</div><div><b>
Position Number: </b>60175; 60177; 91197</div><div><b>
FLSA Status: </b>Exempt</div><div><b>
Posting Salary Range: </b>$66,240 - $88,595</div><div><b>
Office Location: </b>Remote in North Carolina</div><div></div><div><b><br>
POSTING DETAILS:</b></div><div></div><div><b><br>
Make an Impact</b></div><div></div><div><br>
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.</div><div></div><div><b><br>
Why Work for Us</b>?</div><div></div><div><br>
Trillium believes that empowering others begins with supporting our team. We offer our employees:</div><div></div><div><br>
<ul><li>
A collaborative, mission-driven work environment</li><li>
Competitive benefits and work-from-home options for most positions</li><li>
Opportunities for professional growth in a diverse inclusive culture</li></ul></div><div></div><div><br>
Every day, our work changes lives &ndash; from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.</div><div></div><div><br>
If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!</div><div></div><div><b><br>
What We&rsquo;re Looking For</b></div><div></div><div><br>
Trillium Health Resources has a career opening for a Population Health Nurse to join our team! The Population Health Nurse works to identify members that are appropriate for population health programs utilizing data informatics along with providing interventions and education to promote health prevention and promotion. This position will utilize population health management approaches to care in an effort to move beyond episodic patient encounters to address more longitudinal health outcomes.</div><div></div><div><b><br>
On a typical day, you might:</b></div><div></div><div><br>
<ul><li>
Provide intensive care management/care coordination and follow-up to assigned members as a consultant or care manager within specialty programs or regional care teams.</li><li>
Identify trends in the underutilization or overutilization of services.</li><li>
Analyze population-level data from electronic health records and other sources/platforms available.</li><li>
Communicate treatment updates and other member-related activities both verbally and in writing to appropriate personnel and agencies.</li><li>
Provide education about all available services and natural and community supports, treatment options, diagnosis, etc.</li></ul></div><div></div><div><b><br>
Employee Benefits:</b></div><div></div><div><br>
Trillium knows that work/life balance is essential. That&rsquo;s why we offer:</div><div></div><div><br>
<ul><li>
Typical working hours: 8:30 am &ndash; 5:00 pm; flexible work schedules with some roles with management approval.</li><li>
Work-from-home options available for most positions</li><li>
Health Insurance with no premium for employee coverage</li><li>
Flexible Spending Accounts</li><li>
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year</li><li>
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook</li><li>
401k with 5% employer match and immediate vesting</li><li>
Public Service Loan Forgiveness (PSLF) qualifying employer</li><li>
Quarterly stipend for remote work supplies</li></ul></div><div></div><div><b><br>
Qualifications:</b></div><div></div><div><br>
Required:</div><div><ul><li>
Minimum of one (1) year of experience as a Registered Nurse.</li><li>
Fully licensed by the North Carolina State Board of Nursing as a Registered Nurse.</li><li>
Must have a valid driver&rsquo;s license.</li><li>
Must reside within North Carolina.</li><li>
Must be able to travel within catchment as required.</li></ul></div><div></div><div><br>
Preferred:</div><div><ul><li>
Experience working with BH/MH/SU/IDD population.</li><li>
Knowledge of QM and UM procedures, as well as experience in using data analytics for population health management.</li><li>
Certified Managed Care Nurse (CMCN), Certified Case Manager (CCM), Accredited Case Manager (ACM) or equivalent certifications in care management or nursing.</li></ul></div><div><b>
Deadline for Application:</b> Open until filled</div><div></div><div><b><br>
How to Apply</b></div><div></div><div><br>
To be considered, submit your application and resume through our ADP Career Center. Your resume must include:</div><div></div><div><br>
<ul><li>
Employer name, dates of service (month/year), average hours worked per week, and essential job duties</li><li>
Education details (degree type, date awarded, institution, field of study)</li><li>
Licensure/certification information, if applicable</li></ul></div><div></div><div><br>
After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You&rsquo;ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.</div><div></div><div><br>
Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.</div><div></div><div><b><br>
Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.</b></div><div></div><div><i><br>
#Innovation #Technology #Careers #NorthCarolina #BehavioralHealth</i></div></div><div></div>

Population Health Nurse

Duke University

<p></p><div><div><div><div><div><b>Work Arrangement: </b>On-Site
</div></div></div></div><div><div><div><div><b>Requisition Number: </b>267715
</div></div></div></div><div><div><div><div><b>Regular or Temporary: </b>Regular
</div></div></div></div><div><div><div><div><b>Location:
</b>Durham, NC, US, 27704
</div></div></div></div><div><div><div><div><b>Personnel Area: </b>DUKE PRIMARY CARE
</div></div></div></div><div><div><div><div><b>Date: </b>Mar 16, 2026
</div></div></div></div><div></div><div><div><div><div><div>At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.</div><div></div><div><b><br>
About Duke Primary Care</b></div><div></div><div><br>
Pursue your passion for caring with Duke Primary Care, which offers family, adolescent, and internal medicine services as well as urgent, general pediatric, and virtual care at nearly 50 clinic locations across central North Carolina.</div>
<div><b>Duke Nursing Highlights:</b></div><div><br>
</div><ul><li>Duke University Health System is designated as a Magnet organization</li><li>
Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.</li>
<li>Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.</li>
<li>Duke University Health System has 6000 + registered nurses</li>
<li>Quality of Life: Living in the Triangle!</li>
<li>Relocation Assistance (based on eligibility)</li></ul><br>
<div></div><div><b>Population Health Nurse - Duke Primary Care Pediatric</b></div><br>
<div>
</div><div><b>Duke Primary Care Pediatrics</b> provides expert, family-centered care for children from newborns through teens. Their services include well-child and sick visits, immunizations, developmental and behavioral screenings, chronic condition management, and preventive health guidance. With convenient same-day and virtual visits, lactation support, and coordination with Duke&rsquo;s pediatric specialists, these departments deliver high-quality, accessible care across multiple locations, supporting the health and well-being of every child and family.</div><br>
<div></div>
<div><b>
Location:</b> 2609 North Duke Street, Suite 1000, Durham, NC 27704</div><br>
<div></div>
<div><b>
Schedule:</b> Monday - Friday, 8am - 5pm</div><br>
<div></div>
<div><b>
What you will do:</b></div>
<div><b>
The Population Health Nurse</b> partners with pediatric patients with complex health needs, delivering care and education through a dynamic blend of educational telehealth visits and care coordination. This role guides children and their families in managing chronic illnesses, develops and coordinates individualized care plans, and ensures connection to the right resources and support. As an integral member of an interdisciplinary team, the nurse helps families navigate care transitions, empowers them with knowledge and tools, and drives improved, patient-centered health outcomes.</div>
<ul>
<li>Deliver specialized nursing care, create individualized care plans, and educate patients and families while using clinical judgment and following established policies.</li>
<li>Identify the educational needs of patients and caregivers related to their condition, recovery, and transition back to home and community life.</li>
<li>Ensure patients have access to the right care, services, and resources, including coordination with their medical home.</li>
<li>Address the whole person &mdash; medical, emotional, behavioral, psychosocial, and spiritual needs &mdash; for truly comprehensive care.</li>
<li>Actively involve patients and their support systems in decision-making, using a collaborative approach to build self-management skills and encourage long-term healthy behaviors.</li>
<li>Communicate and coordinate with providers and care team members to reduce gaps in care, especially during transitions like hospital-to-home.</li>
<li>Set measurable goals for patients and monitor the quality and success of interventions over time.</li>
<li>Use data from medical records, claims, and program reports to identify patients who need outreach, education, and additional support.</li>
<li>Advocate for patients and work closely with providers to ensure care is evidence-based and aligned with national standards.</li>
<li>Support quality improvement initiatives by educating providers, tracking outcomes, and helping implement best practices.</li>
<li>Apply innovative population health strategies to improve health outcomes and keep care cost-effective.</li>
<li>Participate in performance improvement projects, product evaluations, and clinical research to advance patient care.</li>
<li>Serve as a preceptor and mentor for nursing students and new staff, providing guidance and coaching in both formal and informal settings.</li>
<li>May perform home visits as needed (specific details provided by the department).</li>
<li>Manage the demands of a fast-paced, high-acuity environment with professionalism and resilience.</li></ul><br>
<div></div>
<div><b>
What you will need:
</b></div><div><b>Education</b></div>
<ul>
<li>BSN</li></ul><br>
<div></div>
<div><b>
Experience</b></div>
<ul>
<li>3 years of nursing experience <b><i>required</i></b></li>
<li>Pediatric experience preferred</li><br>
</ul>
<div></div><div><b>Degrees, Licensure, and/or Certification</b></div>
<ul>
<li>Current RN licensure in the state of North Carolina required.</li></ul><br>
<div></div>
<div><b>
Knowledge, Skills, and Abilities</b></div>
<div>
The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are:</div>
<ul>
<li>Organized and motivated by a fast-paced environment</li>
<li>Able to manage multiple tasks/projects simultaneously</li>
<li>Proficient in review and assess needs quickly</li>
<li>Strong with the use of computer software tools and data files</li>
<li>Comfortable with continuous change and self-initiating</li>
<li>Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics)</li></ul><br>
<div></div>
<div><b>
Distinguishing Characteristics of this Level</b></div>
<div>
Additional job expectations include the ability to:</div>
<ul>
<li>Maintain strict confidentiality</li>
<li>Promote programs and services to community</li>
<li>Build effective and trusting relationships with patient/peers</li>
<li>Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests</li>
<li>Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions</li>
<li>Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate</li>
<li>Use data to analyze trends and to verify data</li>
<li>Self-directed and able to organize and manage multiple tasks/projects simultaneously</li>
<li>Ability to promote programs and services to community</li>
<li>Proficient in review of medical records and other patient care information</li></ul><br>
<div></div>
<div>
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.</div><div><b>
Job Title:</b> POPULATION HEALTH NURSE</div>
<div><b>
Job Code:</b> 5555</div>
<div><b>
FLSA:</b> E</div>
<div><b>
Job Level:</b> G1</div>
<div><b>
Revised Date:</b> 05/01/2024</div>
<div><b>
Supervisory Responsibility:</b> No</div><br>
<div></div>
<div>
Duke University is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, (including pregnancy and pregnancy related conditions), sexual orientation, or military status.</div><br>
<div></div>
<div>
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.</div><br>
<div></div>
<div>
Essential Physical Job Functions</div>
<div>
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.</div><br>
</div></div></div></div><div></div><p><br>
<b>Nearest Major Market: </b>Durham
<br>
<b>Nearest Secondary Market: </b>Raleigh</p></div>

Population Health Nurse (PHN) - Durham Pediatrics

ABILITIES FIRST

<div><p><b>PRIMARY PURPOSE OF JOB</b>:</p>
<p>
The Abilities First DD Health Home/ &ldquo;Steps Forward&rdquo; Nurse Care Manager (NCM) plays a pivotal role in managing the the population health needs and gaps in care of the DD Health Home population by adopting a whole-person approach that encompasses both physical and behavioral health aspects of individuals served in the DD Health Home program. The NCM will provide services reflecting the six core services of the DD HH program including care management, care coordination, health promotion, comprehensive transitional care, individual and family support, and referral to community and social support services.</p>
<p>
The NCM will work closely with the DD Health Home Directors, Physician Consultants or APRNs, and the Specialized Healthcare Consultants, as well as other members of the individual&rsquo;s health and care teams to assess current health needs, services, gaps in care and health assessment for each DD Health Home client assigned. The NCM will conduct health assessments, assist in developing and monitoring individual plan health goals and progress related to medical, and social determinants of health needs. The NCM is responsible for providing individual and population health education services. The NCM must provide a minimum of one core service for each assigned DD Health Home client per month. The NCM will utilize electronic health record systems to review, record health information and document health outcomes and services provided.</p>
<p><b>
This description may not include all duties, knowledge, skills, or abilities associated with this position.
</b></p><p><b>ESSENTIAL FUNCTIONS AND PERFORMANCE AREAS</b>:</p>
<ul><li>
Facilitate and participate in an organized, interdisciplinary team approach to care management for all assigned DD Health Home clients as well as the Abilities First DD Health Home overall population.</li><li>
The NCM will meet with individuals assigned to the Abilities First DD HH within the required timelines to explain to the individual the benefits and purpose of the DD HH program.</li><li>
The NCM must conduct a chart review within 30 days of enrollment of the individual into the DD HH program. In this process the NCM will become familiar with the clinical record and individual&rsquo;s history and identify and prioritize health issues which may exist and begin the health care assessment and health plan process.</li><li>
The NCM shall complete a Metabolic Syndrome (MBS) screening with individuals as needed and per the timelines and required frequency as mandated by the DD Health Home contract and provider manual. The DD HH NCM will coordinate with the individual&rsquo;s PCP to determine the recommended time frame for obtaining new lab values.</li><li>
The NCM must document services provided, clinical measures and data obtained, and reviews in each assigned individuals&rsquo; medical records; notes must, at a minimum, document the chart review occurred and be entered into the record within 72 hours of service.</li><li>
As part of comprehensive care management services, the DD HH NCM is responsible for completing standardized, comprehensive assessments of individuals&rsquo; health needs. The health information will be documented on a Health Screen form and entered into the appropriate electronic health record system/s.</li><li>
The DD HH NCM must conduct an annual face-to-face (video or in person) meeting with the individual and parent/guardian to review the health information, discuss healthcare concerns, and help translate health and wellness goals for inclusion in the individual&rsquo;s DD HH healthcare goals.</li><li>
The NCM must monitor and regularly follow up on patients' health progress, adjusting treatment plans as necessary.</li><li>
As part of Care Coordination, health promotion and family support services, the NCM will help develop an overall person-centered health plan for each individual, which coordinates and integrates all clinical and social determinants of health-related needs and services and facilitates the individuals&rsquo; participation in the ongoing revision of their DD HH healthcare goals.</li><li>
The NCM will encourage active individual involvement through appropriate linkages, referrals, coordination, and follow up to needed services and support.</li><li>
The NCM will document individual services in the individual&rsquo;s medical record including, but not limited to, comprehensive care management monitoring for care management gaps. Documentation must meet the DMH/MO HealthNet requirements.</li><li>
The NCM will utilize the DMH/DD identified system on a regular basis and are able to revise DD HH healthcare goals, as necessary.</li><li>
The NCM must perform timely medication reconciliation interventions and sign off on the medication reconciliation when complete, as mandated and defined in the DD Health Home contract and provider manual. A progress note must be entered in the individual record documenting the completion and results of the medication reconciliation. A transfer or hospital follow-up and medication reconciliation review must occur within 7 days for any DD HH enrollee that has been discharged from the hospital.</li><li>
The NCM will develop education to teach individuals how to manage their chronic illnesses and encourage healthy lifestyles.</li><li>
The NCM is responsible for overseeing the health trends of the entire population of individuals, following-up on identified trends impacting the health of the population, addressing high utilizers, participating in health education activities, including, as examples, topics on smoking cessation, disease prevention, and medication adherence.</li><li>
The NCM will coordinate care of DD HH participants enrolled in Managed Care Organizations (MCO) including keeping MCO apprised of individual&rsquo;s needs; follow up with the individual&rsquo;s interactions with the MCO during scheduled visits or phone calls; notify the MCO of individual&rsquo;s discharge from the DD HH, as applicable.</li><li>
The NCM will maintain relationships and coordinate communication with individuals&rsquo; primary care physician. Assist the enrollee in acquiring a primary care physician when needed.</li><li>
The NCM must demonstrate the ability to identify potential abuse and neglect situations and follow protocol according to all applicable regulatory requirements.</li><li>
The NCM must have the ability to bend, sit, stand, and stoop.</li><li>
The NCM must have the ability to establish effective working relationships with co-workers and the public.</li><li>
NCM may not exceed the maximum 1 FTE: 200 individuals served ratio. This includes staff filling these roles on a part-time basis.</li><li>
Other duties as assigned</li></ul>
<p><b>
WORK ENVIRONMENT</b>:
</p><p>The work environment described here is representative of those an employee encounters while performing the essential duties and responsibilities of this job. The work environment is fast-paced and result-oriented, which presents multiple demands with frequent interruptions, constantly shifting schedules and priorities and simultaneous deadlines requiring the employee to be flexible, organized and cooperative. This position has access to confidential information. This requires the employee to maintain a high level of knowledge in confidentiality, agency policy and procedure, and applicable laws.</p>
<p><b>
LEADERSHIP, ETHICS, AND PROFESSIONAL CONDUCT</b>:</p>
<p>
Abilities First employees are expected to model exemplary leadership at all times. This includes representing the agency in a positive, respectful, and professional manner through words, actions, and expressions. Employees are expected to communicate concerns, challenges, and differing perspectives through the established chain of command, using constructive, solution-focused, and professional language rather than judgmental or disparaging commentary. Abilities First expects staff to observe the highest ethical standards, maintain professional conduct above reproach and demonstrate unwavering integrity in all internal and external interactions.</p>
<p><b>
KNOWLEDGE, SKILLS, AND ABILITIES</b>:</p>
<ul><li>
Knowledge and experience teaching self-management</li><li>
Excellent telephone and interpersonal communication skills</li><li>
Ability to multi-task and prioritize, strong organizational skills</li><li>
Strong knowledge of medical terminology</li><li>
Strong knowledge of disease process/disease management and nursing care/body systems throughout the lifespan</li><li>
Computer experience required (Microsoft Office, Microsoft Teams)</li><li>
Electronic health record experience required</li></ul>
<p><b>
CORE COMPETENCIES</b>:
</p><p>Core competencies align with the Abilities First Core Values <b>&ndash; OATH</b></p>
<p><b>
One Team One Mission</b></p>
<ul><li><i>
Contributing to Team Success</i> &ndash; Actively participating as a member of a team to move the team toward the completion of goals.</li><li><i>
Engagement Readiness</i> &ndash; Demonstrating a willingness to commit to one&rsquo;s work and to invest one&rsquo;s time, talent and best efforts in accomplishing organizational goals.</li></ul>
<p><b>
Accountable, respectful service</b></p>
<ul><li><i>
Continuous Improvement</i> &ndash; Originating action to improve existing conditions and processes, identifying improvements opportunities, generating ideas, and implementing solutions.</li><li><i>
Quality Orientation</i> &ndash; Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.</li><li><i>
Technical/Professional Knowledge and Skills</i> &ndash; Having achieved a satisfactory level of technical and professional skill or knowledge in position-related area, keeping up with current developments and trends in area of expertise.</li></ul>
<p><b>
Transparent stewardship</b></p>
<ul><li><i>
Decision Making</i> &ndash; Identifying and understanding issues, problems, and opportunities; comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints, and probable consequences.</li><li><i>
Planning and Organizing</i> &ndash; Establishing courses of action for self and others to ensure that work is completed effectively.</li></ul>
<p><b>
Hold the rope</b></p>
<ul><li><i>
Adaptability</i> &ndash; Maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.</li><li><i>
Leadership Disposition</i> &ndash; Demonstrating the traits, inclinations, and dispositions that characterize successful leaders; exhibiting behavior styles that meet the demands of the leader role.</li></ul>
<p><b>
EDUCATION, TRAINING AND EXPERIENCE REQUIREMENTS</b>:</p>
<ul><li>
(1) Registered Nurse who has a current Missouri or compact RN license recognized by the Missouri State Board of Nursing as an RN OR (2) Licensed Practical Nurse who has a current Missouri or compact LPN license recognized by the Missouri State Board of Nursing as an LPN.</li><li>
At least one year of professional nursing experience required.</li><li>
Experience in the IDD field is preferred, but not required.</li></ul>
<p><b>
ADDITIONAL REQUIREMENTS</b>:</p>
<ul><li>
Must have a valid Missouri Driver&rsquo;s License, acceptable driving record and auto liability insurance that meets the requirements set by Abilities First.</li><li>
Must have secure and reliable high-speed internet in instance of working remotely.</li><li>
Must be able to pass a background screening.
</li></ul><p><b>PHYSICAL CONTEXT AND WORK ENVIRONMENT:</b></p>
<p><b>
Reasonable accommodations may be made to enable individuals with disabilities to perform essential job duties</b>.</p>
<div><div><div><b>
Physical Requirements</b><br>
</div><div><b> Percentage of Work Time Spent on Activity</b></div></div><br>
<div><div>
</div><div><b> 0-24%</b></div><div><b> 25-49%</b></div><div><b> 50-74%</b></div><div><b> 75-100%</b></div></div><br>
<div><div><b>
Seeing:</b> Must be able to see to read documents/reports and focus on computer for an extended period.</div><div></div><div> X</div></div><br>
<div><div><b>
Hearing:</b> Must be able to hear well enough to communicate with coworkers and general public.</div><div></div><div> X</div></div><br>
<div><div><b>
Sitting: </b>Must be able to sit for long periods of time.</div><div></div><div> X</div></div><br>
<div><div><b>
Standing/Walking:</b> Must be able to move about the work area.</div><div> X</div></div><br>
<div></div><div><div><b>
Climbing/Stooping/Kneeling:</b> Must be able to stoop or kneel to pick up items off the floor and filing in a bottom drawer file cabinet.</div><div> X</div></div><br>
<div></div><div><div><b>
Lifting/Pulling/Pushing</b>: Must be able to lift 20 pounds with or without reasonable assistance.</div><div> X</div></div><br>
<div></div><div><div><b>
Driving: </b>Must be able to drive locally for work-related assignments.<br>
</div><div> X</div></div><br>
<div></div><div><div><b>
Grasping/Feeling:</b> Must be able to type, handle documents, and use equipment and electronic devices.<br>
</div><div></div><div> X</div></div><br>
</div>
<p></p>
<ul><li>The work environment is usually a well-lighted, environmentally controlled indoor environment with moderate level of noise.</li><li>
Works in an office environment with the option for some remote work.</li></ul>
<p>
The statements herein are intended to describe the general nature and level of work being performed but are not to be seen as a complete list of responsibilities, duties, and skills required of personnel so classified. Also, they do not establish a contract for employment and are subject to change at the discretion of the employer.</p>
<p>
Created: 12.13.2023; Updated: 11.07.2024; 12.31.2025</p></div>

Nurse Care Manager RN (PT H)

Brilliant Care

<p><b>About Brilliant Care:</b></p><p>Brilliant Care is a very innovative, fast-growing, mission-driven population health management company that assists with value based care initiatives. Our objective is simple: improve health outcomes and reduce total cost of care.</p><p>We proactively identify at-risk hypertensive, diabetic and CHF patients and provide them with personalized access to a nurse care manager who works as an extension to the provider. Using high-touch care coordination and advanced remote technologies, we improve patient compliance and medication adherence while reducing unnecessary ER and hospital visits.</p><p>Essentially, we help improve outcomes substantially, without heavy lift or any out-of-pocket costs for healthcare organizations.</p><p><b>Duties and Responsibilities:</b></p><p>This position will assist healthcare providers and practices to successfully manage their care management and remote patient monitoring program and provide remote patient monitoring services to patients who are enrolled in the program. Must have a passion for educating patient on how to manage their chronic conditions, be self-driven to meet required monthly goals, and have ability to maintain flexibility in a constantly changing environment.</p><p><b>Patient Enrollment:</b></p><ul><li>Enroll patients in Remote Patient Monitoring (RPM).</li><li>Possess the skill to verbally train and educate patients on how to use devices</li></ul><p><b>Data Collection:</b></p><ul><li>Monitor daily capture of patient physiologic data from devices</li><li>Conduct coaching call to remind patients to capture daily data</li><li>Follow-up with non-compliant patients</li></ul><p><b>Care Management:</b></p><ul><li>Act as primary contact for patients to build rapport and maintain patient satisfaction, improvement in health status, and compliance with program</li><li>Analyze collected data and triage out of range readings in a timely manner</li><li>Escalate cases which require provider attention</li><li>Provide health coaching to high-risk diabetic, hypertensive, and congestive heart failure patients</li><li>Document assessment data, education provided, and lifestyle interventions planned in patient charts</li><li>Capture detailed and concise notes of all patient interactions</li><li>Act as a resource to patients and providers in enabling access to the provider and presenting information to the provider for medical decision-making</li></ul><p><b>Provider &amp; practice management:</b></p><ul><li>Understand physician and practice challenges or objections which come in their way of enrolling patients in RPM</li><li>Professionally address provider expressed challenges and workflow related issues to ensure program success</li><li>Possess ability to change workflow and processes as requested by provider or practice</li><li>Communicate with provider of patient needs and institute care changes per provider instructions</li></ul><p><b>Education &amp; Experience:</b></p><ul><li>Active LPN or RN license required. Candidates must hold a current California nursing license. A compact license is strongly preferred; however, candidates with a California license who are willing to obtain additional state licenses will be considered.</li><li>Min 3-year work experience working in practice or healthcare setting.</li></ul><p><b>Location:</b></p><p>Work from home. This particular position requires GA, MD, NY, PA, SC, TX or VA residency, with understanding that this role will be working 8am-5pm CST.</p><p><b>Job Type: </b></p><p>Full-time</p><p><b>Salary:</b></p><p>$26.00 - $28.00 per hour</p><p><b>Benefits:</b></p><ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Parental leave</li><li>Vision insurance</li></ul><p><b>Medical specialties:</b></p><ul><li>Cardiology</li><li>Geriatrics</li><li>Primary Care</li></ul><p><b>Schedule:</b></p><ul><li>Monday to Friday</li></ul><p><b>Application Question(s):</b></p><ul><li>What is your minimum targeted compensation for this role? Please specify whether salaried or hourly.</li><li>Do you have a valid LPN or RN License?</li><li>We require a minimum of 3 years of clinical experience as an LPN or RN. Do you possess at least 3 years of professional nursing experience?</li><li>Do you have a background in bedside, telehealth, skilled nursing or outpatient environments?</li></ul><p><b>Work Location: </b></p><ul><li>Remote</li><li>Must currently reside in the state of California.</li></ul><p>Job Type: Full-time</p><p>Pay: $26.00 - $28.00 per hour</p><p>Benefits:</p><ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Parental leave</li><li>Vision insurance</li></ul><p>Application Question(s):</p><ul><li>Do you have a background in bedside, telehealth, skilled nursing or outpatient environments?  </li><li>Do you have a minimum of 3 years of clinical experience as an LPN or RN?  </li><li>This position pays between $26 and $28 per hour on a W2 basis. Is that within your desired / targeted hourly compensation for a role of this nature?</li><li>What is your current nursing license status? (Active LPN or RN license required. Candidates must hold a current California nursing license. A compact license is strongly preferred)</li></ul><p>Location:</p><ul><li>California (Required)</li></ul><p>Work Location: Remote</p>

Remote Nurse Care Coordinator, Full-time (California)

Trinity Health

<b>Employment Type:</b><br>
Full time
<br><br>
<b>Shift:</b><br>
Day Shift
<br><br>
<b>Description:</b><br>
<b>Position:</b> RN Care Manager
<br><ul>
<li>THMG Academic Internal Medicine - Sherman Pavilion Muskegon, Michigan</li>
<li>Monday - Friday, Business hours</li>
<li>On site position embedded in the practice, one day a week remote work option.</li>
<li>Amazing team to work with!</li>
</ul>
<b>POSITION SUMMARY:</b> The RN Care Manager is a professional nurse who collaborates with physicians, facilities, health care team members and patient/families to manage chronic conditions/complex illness and coordinate care for specific patient populations across the continuum and between care settings as an important member of the Patient Centered Medical Home team.
<br><br>
<b>What the RN Care Manager will:</b><br>
<ul>
<li>Participate and engage their patients in the assessment, planning, monitoring and evaluation of the ongoing care for chronic condition/complex illness management.</li>
<li>Establish plans of care including patient education, self-management, care coordination, and coordinating resources for effective, efficient and appropriate patient care.</li>
<li>Provide ongoing monitoring and evaluation of patient outcomes.</li>
<li>In addition to these responsibilities, the RN Care Manager also performs the duties of population health management, which includes risk stratification to identify high and rising-risk patients. This also includes care coordination and management, patient engagement, and addressing SIOH needs in proactive efforts to improve outcomes, reduce cost, and improve health equity.</li>
<li>The RN Care Manager will assist patients in optimizing their health status; providing interventions designed to avoid hospitalization and emergency room visits.</li>
</ul>
<b>What the RN Care Manager will need:</b><br>
<ul>
<li>Graduate of an accredited school of nursing.Bachelor of Science degree in Nursing required. Master's Degree in Nursing (or actively pursuing Master's Degree in Nursing) preferred. Recent case management experience preferred.</li>
<li>Current licensure to practice nursing in Michigan.</li>
<li>One year of experience in Case Management preferred and three years of clinical experience in nursing required.</li>
</ul>
Our Commitment
<br><br>
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

RN Care Manager -(THMG Academic Internal Medicine - Sherman Pavilion) (Muskegon, Michigan - Business Hours Only)

Evergreen Nephrology

<div><p><b>Who We Are</b></p>
<p>
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.</p>
<p>
We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.</p>
<p><b>
Who You Are</b></p>
<p>
You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You're excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.</p>
<p><b>
Your Role</b></p>
<p>
As a Licensed Practical Nurse (LPN) with Evergreen Nephrology, you are responsible for conducting monthly clinical check-ins, identifying and addressing clinical concerns, reinforcing care plans, escalating issues appropriately, and ensuring clinical documentation accuracy across both the EHR and partner technology platform. This position requires clinical judgment, licensed expertise, and the ability to support patients between office visits while collaborating closely with Evergreen's providers, care teams, and leadership. LPNs are essential to delivering a safe, compliant, clinically credible Connected Care Program.</p>
<p>
The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.</p>
<p>
While this position is <b>fully remote</b>, you must be able to work from 8:30am &ndash; 5pm in the Eastern time zone.</p>
<p><b>
Role Responsibilities</b></p>
<p>
Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:</p>
<ul>
<li>Patient Engagement &amp; Outreach
<ul><li>Perform monthly CCM touchpoints for assigned patient panels.</li>
<li>Build strong, ongoing relationships with patients and caregivers through regular outreach.</li>
<li>Review patient chart data (diagnoses, kidney disease history, medications, labs, imaging, treatment cycles) before calls.</li>
<li>Explain CCM participation and reinforce program benefits.</li>
</ul></li><li>Clinical Assessments &amp; Judgment
<ul><li>Conduct structured symptom assessments (pain, fatigue, neuropathy, SOB, nausea, etc.).</li>
<li>Evaluate changes in condition using licensed clinical judgment.</li>
<li>Assess medication adherence issues, side effects, or confusion about regimen.</li>
<li>Identify clinical red flags requiring escalation (e.g., worsening symptoms, new SOB, uncontrolled pain, concerning vitals).</li>
</ul></li><li>Escalation, Coordination &amp; Provider Communication
<ul><li>Escalate urgent issues based on defined triage pathways (same-business-day or immediate).</li>
</ul></li><li>Collaborate with the provider team on symptom changes, new concerns, or medication-related issues.
<ul><li>Route EHR messages with clinically relevant documentation.</li>
<li>Assist in coordinating care: scheduling follow-up, arranging labs, ensuring nephrology appointments are kept, and reducing missed care.</li>
</ul></li><li>Care Plan Reinforcement &amp; Patient Education
<ul><li>Reinforce provider-developed CKD and chronic disease care plans.</li>
<li>Provide clinical explanation of symptom management instructions (within LPN scope).</li>
<li>Support adherence to medications, lifestyle changes, and follow-up instructions.</li>
<li>Identify social, behavioral, or access barriers and determine appropriate interventions or referrals.</li>
</ul></li><li>Documentation, EHR Updates &amp; Compliance
<ul><li>Document all patient interactions clearly in both the EHR and CCM patient management platform.</li>
<li>Track and log qualifying CCM time accurately for billing compliance.</li>
<li>Ensure documentation meets regulatory, internal QA, and partner expectations.</li>
<li>Maintain high call quality and adherence to scripting and workflow pathways.</li>
</ul></li><li>Quality, Performance &amp; Continuous Improvement
<ul><li>Maintain or exceed:
<ul><li><ul><li>80% monthly engagement</li></ul></li>
<li><ul><li>90% billable conversion</li></ul></li>
<li>High QA/documentation accuracy scores</li>
</ul></li><li>Participate in peer reviews, QA audits, coaching sessions, and continuous education.</li>
<li>Identify recurring patient needs and communicate trends to the Program Manager.</li>
</ul></li><li>Other duties consistent with this role, as assigned.</li>
</ul>
<p><b>Required Qualifications</b></p>
<ul>
<li>Active LPN or Licensed Vocational Nurse (LVN) license</li>
<li>Minimum 1&ndash;2 years of clinical experience in:
<ul><li>Ambulatory care</li>
<li>Population health</li>
<li>Care coordination</li>
<li>Case management</li>
</ul></li><li>Strong clinical assessment, communication, and documentation skills.</li>
<li>Comfortable working in two systems (EHR + CCM platform) simultaneously.</li>
<li>Ability to manage a structured, metric-driven workflow with reliability.</li>
<li>Intermediate skills with MS Office Suite of products including Outlook and Teams</li>
<li>Able to work effectively in a primarily remote environment:
<ul><li>Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended</li>
<li>Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role</li>
<li>Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information</li>
</ul>
</li></ul><p><b>Preferred Qualifications</b></p>
<ul>
<li>Experience in chronic disease management</li>
<li>Prior work in virtual care, remote nursing, or telehealth programs.</li>
<li>Familiarity with CCM regulatory requirements.</li>
<li>Strong patient education and motivational interviewing skills.</li>
</ul>
<p><b>Compensation</b></p>
<p>
The pay range for this role is $55,000-$65,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.</p>
<p>
This role is also eligible for a quarterly bonus.</p>
<p><b>
Benefits
</b></p><p>Evergreen Nephrology's total rewards program is designed to support you in and outside of work. You can expect:</p>
<ul>
<li>Paid time off starting at 4 weeks for full-time employees</li>
<li>12 paid holidays per year</li>
<li>Medical, dental, vision and life insurance, including an HSA with employer match</li>
<li>Reimbursement for continuing medical education for eligible roles</li>
<li>A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure</li>
<li>Paid parental leave</li>
<li>A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology</li></ul><br>
<p></p>
<p>
Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.</p><br>
<p></p>
<p>
If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at recruiting@evergreennephrology.com.</p></div>

Remote Licensed Practical Nurse - Eastern Time

<div><p><b>Who We Are</b></p>
<p>
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.</p>
<p>
We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.</p>
<p><b>
Who You Are</b></p>
<p>
You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You're excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.</p>
<p><b>
Your Role</b></p>
<p>
As a Licensed Practical Nurse (LPN) with Evergreen Nephrology, you are responsible for conducting monthly clinical check-ins, identifying and addressing clinical concerns, reinforcing care plans, escalating issues appropriately, and ensuring clinical documentation accuracy across both the EHR and partner technology platform. This position requires clinical judgment, licensed expertise, and the ability to support patients between office visits while collaborating closely with Evergreen's providers, care teams, and leadership. LPNs are essential to delivering a safe, compliant, clinically credible Connected Care Program.</p>
<p>
The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.</p>
<p>
While this position is <b>fully remote</b>, you must be able to work from 8:30am &ndash; 5pm in the Pacific time zone.</p>
<p><b>
Role Responsibilities</b></p>
<p>
Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:</p>
<ul>
<li>Patient Engagement &amp; Outreach
<ul><li>Perform monthly CCM touchpoints for assigned patient panels.</li>
<li>Build strong, ongoing relationships with patients and caregivers through regular outreach.</li>
<li>Review patient chart data (diagnoses, kidney disease history, medications, labs, imaging, treatment cycles) before calls.</li>
<li>Explain CCM participation and reinforce program benefits.</li>
</ul></li><li>Clinical Assessments &amp; Judgment
<ul><li>Conduct structured symptom assessments (pain, fatigue, neuropathy, SOB, nausea, etc.).</li>
<li>Evaluate changes in condition using licensed clinical judgment.</li>
<li>Assess medication adherence issues, side effects, or confusion about regimen.</li>
<li>Identify clinical red flags requiring escalation (e.g., worsening symptoms, new SOB, uncontrolled pain, concerning vitals).</li>
</ul></li><li>Escalation, Coordination &amp; Provider Communication
<ul><li>Escalate urgent issues based on defined triage pathways (same-business-day or immediate).</li>
</ul></li><li>Collaborate with the provider team on symptom changes, new concerns, or medication-related issues.
<ul><li>Route EHR messages with clinically relevant documentation.</li>
<li>Assist in coordinating care: scheduling follow-up, arranging labs, ensuring nephrology appointments are kept, and reducing missed care.</li>
</ul></li><li>Care Plan Reinforcement &amp; Patient Education
<ul><li>Reinforce provider-developed CKD and chronic disease care plans.</li>
<li>Provide clinical explanation of symptom management instructions (within LPN scope).</li>
<li>Support adherence to medications, lifestyle changes, and follow-up instructions.</li>
<li>Identify social, behavioral, or access barriers and determine appropriate interventions or referrals.</li>
</ul></li><li>Documentation, EHR Updates &amp; Compliance
<ul><li>Document all patient interactions clearly in both the EHR and CCM patient management platform.</li>
<li>Track and log qualifying CCM time accurately for billing compliance.</li>
<li>Ensure documentation meets regulatory, internal QA, and partner expectations.</li>
<li>Maintain high call quality and adherence to scripting and workflow pathways.</li>
</ul></li><li>Quality, Performance &amp; Continuous Improvement
<ul><li>Maintain or exceed:
<ul><li><ul><li>80% monthly engagement</li></ul></li>
<li><ul><li>90% billable conversion</li></ul></li>
<li>High QA/documentation accuracy scores</li>
</ul></li><li>Participate in peer reviews, QA audits, coaching sessions, and continuous education.</li>
<li>Identify recurring patient needs and communicate trends to the Program Manager.</li>
</ul></li><li>Other duties consistent with this role, as assigned.</li>
</ul>
<p><b>Required Qualifications</b></p>
<ul>
<li>Active LPN or Licensed Vocational Nurse (LVN) license</li>
<li>Minimum 1&ndash;2 years of clinical experience in:
<ul><li>Ambulatory care</li>
<li>Population health</li>
<li>Care coordination</li>
<li>Case management</li>
</ul></li><li>Strong clinical assessment, communication, and documentation skills.</li>
<li>Comfortable working in two systems (EHR + CCM platform) simultaneously.</li>
<li>Ability to manage a structured, metric-driven workflow with reliability.</li>
<li>Intermediate skills with MS Office Suite of products including Outlook and Teams</li>
<li>Able to work effectively in a primarily remote environment:
<ul><li>Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended</li>
<li>Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role</li>
<li>Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information</li>
</ul>
</li></ul><p><b>Preferred Qualifications</b></p>
<ul>
<li>Experience in chronic disease management</li>
<li>Prior work in virtual care, remote nursing, or telehealth programs.</li>
<li>Familiarity with CCM regulatory requirements.</li>
<li>Strong patient education and motivational interviewing skills.</li>
</ul>
<p><b>Compensation</b></p>
<p>
The pay range for this role is $55,000-$65,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.</p>
<p>
This role is also eligible for a quarterly bonus.</p>
<p><b>
Benefits
</b></p><p>Evergreen Nephrology's total rewards program is designed to support you in and outside of work. You can expect:</p>
<ul>
<li>Paid time off starting at 4 weeks for full-time employees</li>
<li>12 paid holidays per year</li>
<li>Medical, dental, vision and life insurance, including an HSA with employer match</li>
<li>Reimbursement for continuing medical education for eligible roles</li>
<li>A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure</li>
<li>Paid parental leave</li>
<li>A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology</li></ul><br>
<p></p>
<p>
Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.</p><br>
<p></p>
<p>
If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at recruiting@evergreennephrology.com.</p></div>

Remote Licensed Practical Nurse - Pacific Time

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