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Population Care Manager

Location: Atlanta, GA Additional Locations:
Job Number: 818653 Date posted: 08/12/2019

The Population Care Manager, a Register Nurse, is responsible for coordinating with Ambulatory Medicine physicians (Kaiser Permanente and Affiliated Network), specialists and the healthcare team regarding patient care/population based management for patients in specially defined populations (e.g. specific chronic disease, high risk patients). Based on the KPGA regional Clinical Strategy and Annual Clinical Quality Goals, the Population Care Manager will implement a comprehensive plan focusing on education and self-management. Specifically the Population Care Manager is responsible for, Planning, developing, assessing and evaluating the treatment/ care provided to chronic disease patients, Monitoring levels of appropriateness of therapeutic care (e.g. medication changes per protocols) and implementing strategies to help the member (or caregiver) understand the importance of follow through on the plan of care, Communicating to physicians regarding patient progress by monitoring and evaluating the clinical, functional and psycho-social status, Collaborating with assigned physicians to develop the strategy/ targeted population to assist in improving clinical quality measures, Reviewing the CarePOINT Performance Report to assist in developing the strategy, Ongoing education (formal and informal) with nursing staff at assigned medical offices on chronic condition management.

Essential Responsibilities:

  • Knowledgeable of evidence-based guidelines, treatment protocols and effective models of care for the treatment of the following chronic conditions: Asthma, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Diabetes, Heart Failure and Hypertension.
  • In partnership with Chief and Director of Population Care, Prevention & Health Promotion department, and the Manager of Care Management, assists in the development and standardization of outreach and documentation processes/ protocols.
  • Based on KPGA regional Clinical Quality Strategy, outreaches to members on specific physician's panel to assist in gap closure, improve quality of care and clinical outcomes.
  • Based on input from the physicians: plans, develops, assesses and evaluates treatment / care plan provided to chronic disease members in specifically defined patient populations.
  • Communicates to member when the primary care physician is recommending a change in treatment plan (e.g. medication change/ adjustment).
  • Communicates with physician and/or caregiver regarding patient progress in clinical, functional and psycho-social status.
  • Maintains appropriate documentation on Health Connect and tracks outreach activities according to the policy and procedure in the department of Population Care, Prevention and Health Promotion.
  • Telephonically educates member and/or caregiver on disease process, changes in treatment plan and provides written patient education materials as needed.
  • Contributes to medical and nursing staff education by giving periodic in-service presentations.
  • Utilizes approved algorithms (e.g. Treat to Target) based on the physician's order.
  • Arranges and monitors follow-up appointments to ensure member follows the treatment plan.
  • Encourages and recommends enrollment in the appropriate Healthy Living classes, Health Coaching Program and additional KPGA Care Management Programs (e.g. CVD Management Program).
  • Identifies and recommends opportunities for medical cost savings and regional or inter-regional Best Practices resulting in improved quality of care.
  • Assists patients and family to identify limitations ad barriers to self-management and to explore motivation ad confidence about making healthy behavior changes.
  • Responsible for completing training on CarePOINT Panel Support Tool; proficient in querying and running reports upon three months of hire date.
  • Participates in annual regional and departmental compliance training.
  • Knowledgeable and compliant with Principles of Responsibility.
  • Develops and maintains an awareness of how to report compliance issues and concerns.
  • Performs additional duties and responsibilities as assigned by management.

  • Basic Qualifications:


  • Minimum three (3) years of nursing experience with chronic disease management.

  • Bachelor's degree in nursing OR four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required.
    License, Certification, Registration

  • Current Georgia RN license required (or intent to apply if outside the State of Georgia).

    Additional Requirements:

  • Excellent communication and interpersonal skills.
  • Demonstrated knowledge and experience with behavior change, as well as, self-management and motivational interviewing techniques.

    Preferred Qualifications:

  • Proficient computer skills; experience documenting in an Electronic Medical Record preferred.

  • Master's degree in nursing preferred.
  • Primary Location: Georgia,Atlanta,Regional Office - 10 Piedmont 10 Piedmont Center Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: Varies Working Hours End: Varies Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Individual Contributor Job Category: Nursing Licensed Specialty: Quality Management Department: Quality Travel: Yes, 10 % of the Time Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

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    Through professional practice and leadership, nurses at Kaiser Permanente continually advance the art and science of nursing. But we recognize that what we do is more than clinical practice. We believe that every interaction — whether it is with a patient, a colleague, a physician, or anyone else — has the potential to be extraordinary. And we find that approaching our daily routine with this in mind gives each and every action new meaning and allows us to focus on the moment, empowering us to deliver expert care.

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