Population Health Nurse Case Manager: Care Coordination

CommunityCare, Inc.; Tulsa (OK); Hybrid; USD 65,000 - 85,000; Full time

Job summary

CommunityCare, Inc. seeks a Population Health Nurse Case Manager to assess member needs, coordinate care, and improve health outcomes.

You will develop individualized care plans and engage caregivers, providers, and interdisciplinary teams to address barriers and reduce avoidable utilization. You will identify high-risk members, conduct assessments, monitor progress, coordinate services, and support transitions of care while educating members on chronic condition management and adherence to care

Qualifications

• Knowledge of managed care, case management, chronic conditions, and community resources.
• Strong clinical judgment, organizational, communication, and collaboration skills.
• Ability to prioritize member needs and support member-centered care.
• Proficiency with Microsoft Office applications and electronic care management systems.
• Successful completion of Health Care Sanctions background check.

Responsibilities

• Identify and engage members with complex conditions, care gaps, or elevated health risks using referrals, assessments, and population health data.
• Complete member assessments and develop individualized care plans within nursing scope of practice.
• Provide ongoing outreach to monitor progress, address changing needs, and update care plans.
• Coordinate medical, behavioral health, pharmacy, and community services to support member goals.
• Support transitions of care through timely follow-up, discharge coordination, and connection to needed services.
• Educate members and caregivers on chronic condition management, preventive care, and treatment adherence.
• Address social needs and barriers involving transportation, affordability, access, and health literacy.
• Participate in interdisciplinary care meetings and communicate care plans to members and appropriate providers.
• Maintain timely documentation and support quality improvement, accreditation, and regulatory requirements.
• Perform other job-related duties as required or assigned.

Skills

Clinical judgment

Organizational skills

Communication skills

Collaboration

Prioritize member needs

Education

RN License (OK)

Nursing degree

Discharge planning / case management experience

CCM certification preferred

Tools

Microsoft Office

Electronic care management systems

Job description

CommunityCare, Inc. seeks a Population Health Nurse Case Manager to assess member needs, coordinate care, and improve health outcomes.

You will develop individualized care plans and engage caregivers, providers, and interdisciplinary teams to address barriers and reduce avoidable utilization. You will identify high-risk members, conduct assessments, monitor progress, coordinate services, and support transitions of care while educating members on chronic condition management and adherence to care