population health nurse

Galileo

<div><div><p><b>About Us</b></p>
<p>
Galileo is a team-based medical practice working to improve the quality and affordability of health care for all. Operating across 50 states, Galileo offers high-touch, data-driven, multi-specialty, longitudinal care to diverse and complex patients&mdash;on the phone, in the home, and everywhere in between. Regional and national health plans, employers, and Fortune 500 organizations trust Galileo as the leading solution to improve population health. Founded by Dr. Tom X. Lee, the healthcare pioneer behind One Medical and Epocrates, Galileo is a team of leading innovators from healthcare, technology, and human-centered design. Our mission is to apply that talent and scientific thinking to transform society by solving our largest, toughest healthcare problems, while at the same time bringing patient and provider closer.</p></div><h3 class="jobSectionHeader"><b>
About the Role
</b></h3><p>Are you a Nurse Practitioner who thrives on connecting with patients and making a real difference in their health outcomes? Do you want to leave behind rigid, cookie-cutter systems and join a dynamic, patient-centered organization that values your creativity and clinical expertise? If you're passionate about improving outcomes at scale and energized by meaningful patient engagement, we want you on our team.</p>
<p>
At Galileo, we're transforming healthcare by delivering personalized, comprehensive care to those who need it most &mdash; underserved patients and those with complex medical needs. We use technology, data, and operational rigor to drive outcomes, and we believe the clinicians doing this work are central to that mission. We're a digital-first medical group, and we're proud of the culture we've built: inclusive, collaborative, and deeply committed to health equity.</p>
<p>
Galileo is looking for a culturally Nurse Practitioner to join our Population Health team. In this role, you will use phone and video-based care to provide high-quality, comprehensive follow-up care to patients who are post-hospital discharge.</p>
<p><b>
Here's what you'll do:</b></p>
<ul>
<li>Cover our care needs for our Transitions of Care program.</li>
<li>Day to day work includes telephonic outreach (&quot;cold calls&quot;) and scheduled video/phone visits for patients who have recently been hospitalized and discharged.</li>
<li>Visits focus on: Medication reconciliation, symptom screening, and ordering of any needed follow-up labs, medications or supplies.</li>
<li>You will also navigate conversations with patients to build trust, explain Galileo's care model and connect them to services.</li>
<li>Coordinate care across settings &mdash; hospital and ED transitions, pharmacies, and community providers &mdash; to keep patients connected and moving forward.</li>
<li>Collaborate with our nursing team</li>
<li>Be accountable to individual performance targets while contributing to team-level population health goals</li>
</ul><h3 class="jobSectionHeader"><b>How We Work</b></h3>
<p>
Galileo is a 24/7 medical group that provides high-quality, comprehensive primary care as well as transition of care follow-up. We work in 4-hour shifts (mornings, afternoons, evenings, overnight on weekdays and weekends). At 24+ hours you will be considered full-time and benefits eligible. Providers are expected to work weekends on a monthly basis, specific schedule will be influenced by total hours committed and patient care demands.</p>
<p>
We are currently looking for a Nurse Practitioner with an active license in either MA and/or CT who is available to work 32-36 hours/week.</p>
<p><b>
Compensation</b></p>
<p>
$78/hour (regular rate) and $90/hour (premium rate)</p>
<h3 class="jobSectionHeader"><b>
About You</b></h3>
<p>
You're a people person. You love connecting with others and have an innate ability to build rapport quickly &mdash; even on a cold call. Your curiosity and creativity come through in every patient conversation, and you're looking for an environment where those instincts are an asset, not an afterthought.</p>
<p>
We look for passionate clinicians who are invested in solving complex problems that impact millions of lives and excited about fixing what's broken to improve care quality and health outcomes for everyone. We believe in a culture that fosters teamwork, excellence, and sound decision-making &mdash; built on mutual respect and trust.</p>
<p><b>
We would love to hear from you if you have the following or equivalent experience:</b></p>
<ul>
<li>Certified Nurse Practitioner in Adult, Family or Geriatrics</li>
<li>Active state licensure in MA and/or CT, with the ability to obtain additional state licensures</li>
<li>5+ years of post-graduate clinical experience in Primary Care or Geriatrics</li>
<li>2 of those years may be substituted by time spent working at a Skilled-Nursing facility or Long Term Care facility</li>
<li>Direct experience engaging Medicare and Medicaid populations managing complex, comorbid conditions</li>
<li>Motivational interviewing skills you can draw on to help patients make meaningful behavioral changes</li>
<li>Comfort in a digital-first environment, with experience in or a genuine appetite for virtual care delivery</li>
<li>Solid tech proficiency; familiarity with Google Suite and Slack is a plus</li>
<li>Excellent written and verbal communication skills</li>
<li>Bilingual in English and Spanish, including cultural fluency, is a strong bonus</li>
</ul>
<p><b>How We Care for You</b></p>
<ul>
<li>Flexible scheduling - design the schedule that works best for YOU</li>
<li>Competitive health, vision and dental plans</li>
<li>Company paid short and long term disability</li>
<li>12 weeks paid parental leave</li>
<li>Malpractice insurance provided, including tail coverage</li>
<li>401(k) with company match</li></ul><p></p><div><p><b><br>
How We Hire</b></p>
<p>
Galileo Health is an equal-opportunity employer and welcomes applicants from all backgrounds.</p>
<p>
We have recently become aware of the fraudulent use of our name on job postings and via recruiting emails that are illegitimate and not in any way associated with us. We will never ask you to provide sensitive personal information as part of the recruiting process, such as your social security number; send you any unsolicited job offers or employment contracts; require any fees, payments or access to any financial accounts; and/or conduct text-only interviews. If you suspect you are being scammed or have been scammed online, you may report the crime to the Federal Bureau of Investigation and obtain more information regarding online scams at the Federal Trade Commission.</p></div></div>

Population Health Nurse Practitioner (Remote, MA License)

Population Health Nurse Practitioner (Remote, CT License)

Teachers Health Trust

<p><b>ESSENTIAL DUTIES AND RESPONSIBILITIES</b></p><p>The Nurse Practitioner is responsible for the following essential functions:</p><p>&middot; Review and track members diagnosed with diabetes, including review of medical history, medication regimens, laboratory results, and blood glucose data</p><p>&middot; Implement and assist in facilitating individualized diabetes care plans in collaboration with providers and interdisciplinary care teams</p><p>&middot; Provide tertiary clinical support and education related to insulin administration, blood glucose monitoring, medication adherence, and symptom management</p><p>&middot; Educate members and families on diabetes self-management, including nutrition, physical activity, lifestyle modification, glucose testing, and sick-day guidelines</p><p>&middot; Collaborate with physicians, pharmacists, case managers, and behavioral health partners to coordinate care and reduce complications of diabetes</p><p>&middot; Support population health initiatives and clinical programs focused on diabetes prevention, disease management, and improved health outcomes</p><p>&middot; Provide emotional support and motivational coaching to members and families managing chronic diabetes-related challenges</p><p>&middot; Educate providers on program requirements and available resources</p><p>&middot; Participate in quality improvement initiatives, data review, and outcome monitoring related to diabetes care</p><p>&middot; Stay current on diabetes treatment guidelines, emerging therapies, and best practices through continuing education and professional development</p><p><b>REQUIRED QUALIFICATIONS</b></p><p>&middot; Active, unrestricted Registered Nurse (RN) license in the State of Nevada (or compact state)</p><p>&middot; Bachelor of Science in Nursing (BSN) required; Master&rsquo;s degree preferred</p><p>&middot; Demonstrated knowledge of diabetes pathophysiology, medications, insulin therapies, and diabetes technologies</p><p><b>PREFERRED QUALIFICATIONS</b></p><p>&middot; Certified Diabetes Care and Education Specialist (CDCES) or eligibility to obtain certification within a defined timeframe</p><p>&middot; Experience in population health, care management, health plan, or outpatient clinical settings</p><p>&middot; Minimum of three (3) years of clinical nursing experience, with at least two (2) years focused on diabetes care, chronic disease management, or care coordination</p><p>&middot; Experience working with multidisciplinary teams, vendors, or value-based care programs</p><p>&middot; Strong patient education, motivational interviewing, and coaching skills</p><p><b>KNOWLEDGE, SKILLS, AND ABILITIES</b></p><p>&middot; Advanced knowledge of diabetes management standards and evidence-based clinical guidelines</p><p>&middot; Ability to translate complex medical information into clear, actionable guidance for members</p><p>&middot; Strong interpersonal, communication, and relationship-building skills</p><p>&middot; Excellent organizational skills with the ability to manage multiple cases and priorities</p><p>&middot; Proficient in care management platforms and Microsoft Office applications</p><p>&middot; Ability to work independently while collaborating effectively within a team environment</p><p><b>PHYSICAL AND WORKING CONDITIONS</b></p><p>&middot; Office-based or remote work environment, and on-site or community-based engagements</p><p>&middot; May require prolonged periods of sitting, telephone use, and computer work</p><p>&middot; Occasional travel may be required for member engagement, physician engagement, vendor meetings, or community events</p><p><b>CORE COMPETENCIES</b></p><p>&middot; Member-Centered Care</p><p>&middot; Clinical Excellence</p><p>&middot; Collaboration and Teamwork</p><p>&middot; Accountability and Integrity</p><p>&middot; Continuous Improvement</p><p>Job Type: Full-time</p><p>Pay: $75,000.00 - $125,000.00 per year</p><p>Work Location: Hybrid remote in Las Vegas, NV 89121</p>

Registered Nurse

URBAN HEALTH PLAN, INC.

<div>
 <strong>
  Job Description
  <br/>
  <br/>
 </strong>
 <strong>
  Position Summary:
  <br/>
  <br/>
 </strong>
 The Bilingual English/Spanish Care Transitions Nurse (RN) is responsible for supporting patients during critical transitions of care, particularly following emergency room visits, hospital discharges, and specialty care episodes. This role ensures timely follow-up, medication reconciliation, care coordination, and patient education to reduce readmissions and prevent gaps in care.
 <br/>
 <br/>
 The Care Transition Nurse works closely with primary care providers, specialists, care management teams, and community partners to ensure continuity of care and improve health outcomes for high-risk and medically complex patients.
 <br/>
 <br/>
 This role supports the organization's population health, quality improvement, and value-based care initiatives by facilitating safe transitions and promoting patient engagement in ongoing care.
 <br/>
 <br/>
 As part of the Virtual Care Center- this role is a fully remote position. Although remote, incumbents are required to engage in in person and Bronx-based service throughout training period, and throughout employment for trainings and meetings when requested. Required schedule included Monday through Friday 9am-6pm shift.
 <br/>
 <br/>
 <strong>
  Minimum Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Associates or Bachelors in Nursing is required.
  </li>
  <li>
   NYS Licensed Registered Nurse is required.
  </li>
  <li>
   Minimum of 2-5 years of clinical nursing experience is required in ambulatory care, community health, or related setting.
  </li>
  <li>
   Bilingual Spanish/English is required.
  </li>
  <li>
   Strong care coordination and patient communication skills
  </li>
  <li>
   Knowledge of hospital discharge processes and transitional care management
  </li>
  <li>
   Ability to identify clinical and social determinants of health impacting care
  </li>
  <li>
   Proficiency in electronic health records and care documentation
  </li>
  <li>
   Ability to work collaboratively across multidisciplinary teams
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Key Duties
  <br/>
  <br/>
 </strong>
 <strong>
  Transitional Care Management &amp; Patient Follow-Up
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conduct outreach to patients following hospital or emergency department discharge
  </li>
  <li>
   Complete Transitional Care Management (TCM) workflows in accordance with CMS guidelines
  </li>
  <li>
   Ensure patients receive timely follow-up appointments with primary care providers or specialists
  </li>
  <li>
   Facilitate specialty care coordination by assisting patients in navigating referrals, scheduling appointments, and ensuring appropriate follow-up with specialty providers.
  </li>
  <li>
   Perform medication reconciliation and assess for medication adherence and safety concerns
  </li>
  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
  </li>
  <li>
   Perform medication reconciliation and assess for medication adherence and safety concerns
  </li>
  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Care Coordination &amp; Continuity of Care
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Coordinate care between hospital systems, primary care providers, specialists, and community resources.
  </li>
  <li>
   Review discharge summaries and hospital documentation to ensure appropriate follow-up care
  </li>
  <li>
   Facilitate referrals, diagnostic testing, and specialty appointments as needed
  </li>
  <li>
   Support patients in understanding discharge instructions and treatment plans Ensure patients do not fall through gaps in care during transitions
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  High-Risk Patient Management
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Identify high-risk patients based on clinical, social, and utilization risk factors
  </li>
  <li>
   Provide additional monitoring and outreach for patients at risk of readmission
  </li>
  <li>
   Collaborate with care managers, CHWs, behavioral health providers, and social services to address complex patient needs
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Patient Education &amp; Engagement
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Provide patient-centered education regarding diagnosis, medications, warning signs, and follow-up care
  </li>
  <li>
   Promote patient self-management and adherence to treatment plans
  </li>
  <li>
   Encourage ongoing engagement with primary care services
  </li>
  <li>
   Address health literacy and cultural considerations to improve understanding and compliance
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Data Documentation &amp; Reporting
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Document patient encounters and care coordination activities in the EHR
  </li>
  <li>
   Track outreach efforts, successful contacts, and follow-up outcomes
  </li>
  <li>
   Support reporting for Transitional Care Management (TCM) billing and quality measures
  </li>
  <li>
   Contribute to organizational reporting related to readmission reduction and care continuity
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Quality Improvement &amp; Population Health
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Participate in initiatives aimed at reducing avoidable hospitalizations and emergency room utilization
  </li>
  <li>
   Identify patterns or barriers affecting successful transitions of care
  </li>
  <li>
   Collaborate with leadership to improve workflows related to discharge follow-up and care coordination
  </li>
  <li>
   Support quality improvement initiatives related to patient access and care continuity
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Collaboration &amp; Team Integration
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Work closely with providers, care management teams, call center staff, and telehealth teams to coordinate patient care
  </li>
  <li>
   Communicate patient updates and concerns to primary care teams in a timely manner
  </li>
  <li>
   Participate in multidisciplinary meetings focused on high-risk patient management and care planning
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Starting Compensation:
 </strong>
 Minimum $86,560 per year; Maximum $98,560 per year contingent on degree and years of nursing experience.
 <br/>
 <br/>
 <strong>
  As a full time associate at Urban Health Plan, you'll enjoy:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family
  </li>
  <li>
   Dental, Vision, and Prescription Coverage
  </li>
  <li>
   401(k) Retirement Savings (including 3% annual employer contribution)
  </li>
  <li>
   Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!)
  </li>
  <li>
   Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits)
  </li>
  <li>
   Entertainment Discount Programs
  </li>
  <li>
   Employee Assistant Program
  </li>
  <li>
   Eligibility to apply for Public Service Loan Forgiveness Program (PSLF)
  </li>
  <li>
   Fitness Discounts and Perks through our medical plan.
  </li>
  <li>
   $50,000 term life Insurance
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  About Urban Health Plan
  <br/>
  <br/>
 </strong>
 At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, 50 years ago. That tradition continues today by promoting excellence in everything that we do.
 <br/>
 <br/>
 <em>
  UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status.
  <br/>
  <br/>
 </em>
 Job Requirements
</div>


Care Transitions Nurse (RN)

Whittier Street Health Center

<p><b>Compensation &amp; Benefits Include:</b></p><ul><li>$42.00&ndash;$48.00 hourly</li><li>Health, dental, and vision insurance</li><li>Employer-funded pension &amp; life insurance</li><li>403(b) retirement plan</li><li>Paid time off and holidays</li><li>CME reimbursement and licensure support</li></ul><p><b>The Opportunity:</b></p><p>Whittier Street Health Center is seeking a full-time Clinical Programs Nurse to join our Center for Health Equity Research. In this role, you will support the coordination and delivery of clinical programs, working closely with care teams and patients to manage chronic conditions, support preventive initiatives, and contribute to research-related activities.</p><p>The Center for Health Equity Research advances equitable health outcomes through community-centered care and clinical research. By integrating preventive care, specialty clinics, and evidence-based interventions, the Center works to address chronic disease disparities, improve access, and enhance long-term outcomes for the communities we serve.</p><p><b>Key Responsibilities:</b></p><ul><li>Coordinate clinical program activities including Remote Patient Monitoring, specialty clinics, and prevention initiatives</li><li>Identify and engage eligible patients through outreach, referrals, and registry review</li><li>Provide patient education on chronic disease management, screening, and follow-up care</li><li>Support clinical research activities including recruitment, enrollment, and data collection</li><li>Ensure compliance with IRB protocols, regulatory standards, and Good Clinical Practice (GCP)</li><li>Coordinate referrals and support navigation to specialty and supportive services</li><li>Document patient interactions and maintain accurate clinical and research data</li><li>Collaborate with care teams to improve workflows, program outcomes, and quality initiatives</li></ul><p><b>Qualifications:</b></p><ul><li>Licensed Registered Nurse in the Commonwealth of Massachusetts</li><li>3&ndash;5 years of RN experience, preferably in primary care, population health, or research settings</li><li>Experience with phlebotomy required</li><li>Experience with EMR systems required; EPIC strongly preferred</li><li>Proficiency in Microsoft Office and standard computer applications</li><li>Strong communication, organizational, and time-management skills</li><li>Ability to work effectively in multidisciplinary and multicultural environments</li><li>Current Basic Life Support (BLS) certification</li></ul><p><b>Join Our Team!</b></p><p>Whittier Street Health Center is dedicated to advancing health equity and delivering high-quality, culturally responsive care. We are committed to building a diverse, inclusive workplace where every team member contributes to improving the health and well-being of our community. If you&rsquo;re ready to make a meaningful impact, we&rsquo;d love to hear from you.</p><p>#indlp</p><p>Pay: $42.00 - $48.00 per hour</p><p>Benefits:</p><ul><li>403(b)</li><li>Continuing education credits</li><li>Dental insurance</li><li>Disability insurance</li><li>Employee assistance program</li><li>Flexible spending account</li><li>Health insurance</li><li>Health savings account</li><li>Life insurance</li><li>Paid time off</li><li>Referral program</li><li>Retirement plan</li><li>Tuition reimbursement</li><li>Vision insurance</li></ul><p>Application Question(s):</p><ul><li>How many years of experience do you have working as a Registered Nurse?</li><li>Are you currently licensed as a Registered Nurse in Massachusetts?</li><li>Do you have experience performing phlebotomy?</li></ul><p>Ability to Commute:</p><ul><li>Boston, MA 02120 (Required)</li></ul><p>Work Location: In person</p>

Clinical Programs Nurse | Center for Health Equity Research | Boston

Zócalo Health

<div>
 <strong>
  Registered Nurse (RN) &ndash; Enhanced Care Management (ECM) California
  <br/>
  <br/>
 </strong>
 Remote (Full Time)
 <br/>
 <br/>
 Compensation: $80,000/ year
 <br/>
 <br/>
 <strong>
  About Us
  <br/>
  <br/>
 </strong>
 Z&oacute;calo Health is a tech-enabled, community-oriented primary care organization serving people who have historically been underserved by the one-size-fits-all healthcare system. We partner with health plans, providers, and community organizations to deliver culturally competent primary care, behavioral health, and social care.
 <br/>
 <br/>
 Our model is built for populations with high medical and social complexity, where fragmented care drives poor outcomes and unnecessary cost. We combine local, community-based teams with virtual care and modern technology to deliver coordinated, whole-person care where members live and receive support.
 <br/>
 <br/>
 Founded in 2021, Z&oacute;calo Health is backed by leading healthcare and mission-aligned investors and is scaling rapidly across states and populations. We are building a durable care platform designed to perform in constrained healthcare environments and to lead the shift toward accountable, value-based care.
 <br/>
 <br/>
 <strong>
  Role Description
  <br/>
  <br/>
 </strong>
 The Registered Nurse (RN) &ndash; Enhanced Care Management (ECM) will join Z&oacute;calo Health during a period of rapid growth and increasing operational complexity. This role exists to help scale and execute a community-oriented primary care model that delivers measurable outcomes for high-need members and health plan partners.
 <br/>
 <br/>
 As part of a fast-growing team, you will be responsible for providing clinical oversight, supporting care coordination, and ensuring documentation and workflows meet health plan requirements. You will partner closely with Community Health Workers (CHWs), Behavioral Health Care Managers (BHCMs), and providers to support high-risk members and ensure coordinated, high-quality care delivery.
 <br/>
 <br/>
 This position reports to
 <strong>
  Clinical Operations Leadership
 </strong>
 .
 <br/>
 <br/>
 The
 <strong>
  Registered Nurse (RN) &ndash; Enhanced Care Management (ECM)
 </strong>
 will contribute in the following ways:
 <br/>
 <br/>
 <ul>
  <li>
   Provide clinical oversight and guidance to CHWs and BHCMs, including escalation support for complex and high-risk patients
  </li>
  <li>
   Lead clinical case reviews, identifying gaps in care and ensuring care plans are clinically appropriate and aligned with health plan requirements
  </li>
  <li>
   Support care coordination across medical, behavioral health, and social needs, including collaboration with external providers and hospitals
  </li>
  <li>
   Conduct and document medication reconciliation, particularly following transitions of care
  </li>
  <li>
   Support transitions of care (TOC), including post-discharge follow-up and readmission risk mitigation
  </li>
  <li>
   Ensure documentation is accurate, structured, and compliant with health plan standards and audit expectations
  </li>
  <li>
   Partner with care teams to address social determinants of health, including LTSS coordination and social risk integration into care plans
  </li>
  <li>
   Identifies gaps in care, supports care team decision-making, and drives continuous improvement in care delivery and patient outcomes
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Active Registered Nurse (RN) license in California
  </li>
  <li>
   3+ years of clinical nursing experience
  </li>
  <li>
   Experience in care management, population health, or community-based care
  </li>
  <li>
   Bilingual (Spanish)
  </li>
  <li>
   Experience working with Medicaid or underserved populations
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Experience with Medi-Cal managed care plans
  </li>
  <li>
   Familiarity with CalAIM Enhanced Care Management (ECM) programs
  </li>
  <li>
   Experience addressing social determinants of health and community-based care models
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  What you can expect from Z&oacute;calo Health
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Competitive salary
  </li>
  <li>
   Equity compensation package
  </li>
  <li>
   Comprehensive benefits including medical, dental, and vision 401k
  </li>
  <li>
   Generous PTO policy (up to 15 days per year for FT employees)
  </li>
  <li>
   Flexible PTO policy - take the time you need to recharge
  </li>
  <li>
   $1,000 home office stipend
  </li>
  <li>
   We provide the equipment needed for this role.
  </li>
  <li>
   Opportunity for rapid career progression with plenty of room for personal growth.
   <br/>
   <br/>
  </li>
 </ul>
 You must be authorized to work in the United States. Remote work can be done from anywhere in the U.S.
 <br/>
 <br/>
 At Z&oacute;calo Health Inc., we see diversity and inclusion as a source of strength in transforming healthcare. We believe building trust and innovation are best achieved through diverse perspectives. To us, acceptance and respect are rooted in an understanding that people do not experience things in the same way, including our healthcare system. Individuals seeking employment at Z&oacute;calo Health are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
 <br/>
 <br/>
 Those seeking employment at Z&oacute;calo Health are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status or disability status.
</div>


Registered Nurse (RN)

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)

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