Job DetailsJob Location: Coos Bay, OR 97420Position Type: Full TimeEducation Level: 4 Year DegreeSalary Range: $92,705.60 - $115,876.80 Salary/yearThis position is a covered position as defined in the Coquille Indian Tribe Chapter 185 Child Protection Ordinance. Candidate must pass a pre-employment drug screen, Criminal, and Character Background Check. SUMMARY OF MAJOR FUNCTIONS Under the direction of the Health and Wellness Division (HWD) Chief Operating Officer (COO), the Population Health Nurse Supervisor provides leadership, supervision, and clinical guidance to the Population Health Nurse Case Management team. This position fosters collaboration across the healthcare system to promote the delivery of high-quality, culturally responsive, patient-centered, and cost-effective care. The Population Health Nurse Supervisor is responsible for developing, implementing, and leading the Health and Wellness Division's Population Health Case Management Program, utilizing a population health approach to improve health outcomes for patients served by the Ko-Kwel Wellness Center (KWC) across all locations. The position allocates approximately 30% of time to administrative, supervisory and operational responsibilities and 70% to providing comprehensive nurse case management and care coordination for patients with chronic, complex, and high-risk health conditions. Regular travel between KWC locations is required to support staff and provide patient services. ESSENTIAL DUTIES AND RESPONSIBILITIES Administrative, Supervisory and Operational Duties (30%) Provide leadership, supervision, and performance management for the Population Health Nurse Case Managers and other case management staff, including Traditional Health Care Workers, as the program expands. Develop, implement, and maintain policies, and standard operating procedures (SOPs) for the Nurse Case Management Program to ensure consistency, quality, and compliance. Lead the development, implementation, and ongoing evaluation of the Health and Wellness Division's Nurse Case Management Program, ensuring continuous quality improvement, regulatory compliance, and alignment with organizational goals. Develop and oversee communication strategies and program resources to promote Nurse Case Management services to patients, providers, and community partners through appropriate communication channels. Develop, implement, and continuously improve workflows and processes that support accurate documentation, coding, billing, and insurance reimbursement. Identify alternative funding opportunities, including grants, partnerships, and reimbursement initiatives, to support the long-term sustainability of the Nurse Case Management Program. Case Management (70%) Serve as the primary point of coordination among patients, healthcare providers, specialists, hospitals, and community resources to ensure seamless, patient-centered continuity of care. Utilize Electronic Health Record (EHR) population health reports and other available data to identify patients at high risk or with chronic and complex medical conditions who may benefit from case management services. Collaborate with interdisciplinary care teams to develop, implement, and optimize population health initiatives that improve patient outcomes. Develop and maintain a process for identifying and enrolling high-risk patients in case management services. Conduct comprehensive assessments, develop individualized care plans, and collaborate with patients, families, and the healthcare team to coordinate services, address barriers to care, and achieve optimal health outcomes. Advocate for evidence-based treatment and interventions by applying current clinical guidelines and best practices in care management. Monitor patient progress and revise care plans as needed to address changing healthcare needs. Maintain appropriate and essential resources, procedures, and policies to ensure the delivery of high-quality nurse case management services. Assess patients' ability to access healthcare services and identify barriers to care, including transportation, food insecurity, financial challenges, housing instability, and other social determinants of health. Connect patients with appropriate internal and community resources to address identified health, social, and support needs and promote continuity of care. Provide patient and family education regarding disease prevention, chronic disease self-management, medication adherence, and healthy lifestyle practices. Coordinate transitions of care for patients discharged from hospitals, emergency departments, skilled nursing facilities, or other care settings. Ensure timely follow-up, medication reconciliation, and coordination of post-discharge services to reduce avoidable readmissions. Maintain policies, procedures, and clinical guidelines that support effective, compliant, and high-quality nurse case management services for patients of the Ko-Kwel Wellness Center in collaboration with KWC Leadership team Coordinate medical appointments, referrals, specialty care, and ancillary services while serving as a patient advocate to improve access to care and facilitate communication among providers and community partners. Participate in quality improvement and patient safety activities for improving care and outcomes for patients. Document patient assessments, interventions, care plans, education, coordination activities, and outcomes accurately and timely within the Electronic Health Record (EHR). Maintain accurate patient problem lists, preventive health screenings, health maintenance records, and other clinical documentation within the EHR. Creates and manages patient panels within OCHIN Epic Population Health to support chronic disease management, preventative care and wellness initiatives. Participate in HWD meetings as requested. Other duties as assigned. The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as detailed description of all the work requirements that may be inherent in the job. This position may involve transporting Native Americans and Non-Native patients and clients in the KWC, employee-owned vehicles and rental vehicles to and from a variety of Ko-Kwel Wellness Center functions and activities. PHYSICAL REQUIREMENTS Requires the ability to communicate orally, repetitive movement of the wrists, hands and/or fingers, often requires walking, standing, sitting for extended periods of time, raising or lowering objects, stooping and occasionally requires lifting up to 50 pounds. Will often be required to travel by automobile, commercial or private carrier. Local travel is frequently required; statewide and national travel is occasionally required. The individual must perform the essential duties and responsibilities with or without reasonable accommodation efficiently and accurately without causing a significant safety threat to self or others. REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES Individuals must possess the following knowledge, skills and abilities or be able to explain and demonstrate that they can perform the essential functions of the job, with or without reasonable accommodation, using some other combination of skills and abilities. Excellent verbal and written communication skills with strengths in team building, and cooperative problem solving. Ability to consistently demonstrate a professional, courteous, and supportive demeanor by utilizing strong interpersonal and communication skills to effectively manage stressful, sensitive, and emotionally charged situations. Ability to foster an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the Coquille Indian Tribe. Ability to make decisions independently in accordance with established policy and procedures. Strong proficiency with Electronic Health Records (EHR) and population health software. Proficiency in using computer systems, and standard business software, including Microsoft Office applications (Word, Excel, Outlook), to prepare correspondence, reports, maintain electronic records, and support daily operations. Ability to negotiate and monitor contracts for services in accordance with the Coquille Indian Tribe’s Fiscal Ordinance. Ability to apply basic mathematical principles, including addition, subtraction, multiplication, division, and percentages, with accuracy and attention to detail. Ability to work cooperatively with other departments to accomplish assigned tasks; ability to develop good working relationships with other departments in the organization Ability to organize, set priorities and exercise sound independent judgment within areas of responsibility. QualificationsREQUIRED QUALIFICATIONS Licensure as a Registered Nurse in Oregon. Bachelor of Science degree in nursing, preferred. Associate Degree of Nursing. Minimum 2 years of supervisory experience. Minimum 3 years’ experience working in quality improvement, population health, case management or utilization management. Case Management certification, or the ability to obtain certification within six (6) months of hire. In lieu of certification at the time of hire, candidates must have at least three (3) years of direct case management experience. Excellent written and verbal communication skills required. Proficiency in Microsoft Office applications (including Outlook, Word, Excel, and PowerPoint) and the ability to effectively use electronic health record (EHR) systems and other applications. Experience with electronic health records (EHR). Willingness and ability to adapt individual interventions, programs, and policies to fit the cultural context of the individual, family, or community. Current and valid Oregon driver’s license in good standing is required with no insurability restrictions from the Tribe’s insurance carrier. PREFERRED QUALIFICATIONS Experience with EHR population health, integrated chronic disease management and patient portal software preferred. Previous OCHIN-Epic experience. Knowledge of Native American culture.

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