Population Health Care Manager RN Ryan White

4 weeks ago


Hollywood, Florida, United States Community Care Plan Full time
Job Title: Population Health Care Manager RN Ryan White

Job Summary:

The Population Health Care Manager RN-Ryan White plays a vital role in supporting the practitioner-patient relationship by providing cost-effective, evidence-based care to individuals living with HIV/AIDS. This position complements the established plan of care, focusing on preventing disease exacerbation and complications.

Key Responsibilities:

  • Coordinate and educate clients on disease management, promoting compliance with preventative care measures.
  • Develop and implement healthcare interventions to facilitate care at the lowest level possible, empowering clients to self-manage chronic conditions.
  • Collaborate with a multidisciplinary team to identify clients with high morbidity, risk, or barriers to access or retention in care, and implement a plan to address these needs.
  • Analyze clinical information to determine eligibility and appropriateness for enrollment in the Ryan White Disease Case Management program.
  • Provide outreach to clients with chronic conditions, not well managed or with multiple gaps in care, and offer preventive services.
  • Conduct thorough needs assessments, including risk stratification, to determine health, psychological, educational, and social needs, and the level of care requirements.
  • Develop individualized care plans in collaboration with the physician and client, setting Specific, Measurable, Achievable, Realistic, and Time-bound (SMART) goals.
  • Collaborate with the healthcare team to assess progress toward individual health care goals, optimize patient adherence to the medical plan of care, and complete electronic referrals and medication refills as needed.
  • Update client care plans as changes in status occur and communicate with the multidisciplinary team as indicated.
  • Provide client education on disease process and healthy lifestyle changes, reminders, and/or telephone calls to improve self-management of specific conditions.
  • Maintain requirements of documentation as reflected in the Ryan White Service Delivery Model to meet compliance with quality standards and acknowledge patient confidentiality at all times.

Requirements:

  • Registered nurse licensure in the State of Florida.
  • Certified case manager or certified diabetes educator preferred.
  • Minimum of five years of clinical experience or two years of case or disease management experience in a Ryan White service provider, health system, health maintenance organization, or disease management organization with experience in HIV/AIDS care.
  • Knowledge of Microsoft Office and internet software.


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