Population Health Care Manager RN

Who We Are:

SAC Health empowers our patients and their families to live vibrant and healthy lives through culturally responsive, exceptional care. Patient‑centered, whole‑person care. Our unique, full scope, team‑based approach is what makes SAC Health the provider of choice for patients.

Top‑Tier Patient Satisfaction Scores | Largest Teaching Health Center FQHC | 11 Locations offering 44 Specialties | Certified Multi‑Site Approved for NHSC & NCLRP loan forgiveness programs

The Population Health Care Manager (RN) is responsible for improving health outcomes for a large population of patients with diabetes, hypertension, and other chronic conditions within an outpatient primary care environment. Through primarily telephonic and campaign‑based outreach, the RN delivers proactive assessment, education, care coordination, and clinical intervention.

The role leverages data analytics, risk stratification, and evidence‑based guidelines to identify care gaps and prioritize services. Working in close partnership with providers and interdisciplinary teams, the RN supports continuity of care, referral management, and successful transitions across settings. This position is accountable for contributing to organizational performance on quality measures, including UDS and value‑based benchmarks. The Population Health Care Manager also provides triage and cross coverage support to maintain patient access and operational efficiency.

5 days per week, 8 hours per day, Mon‑Fri 7:30am‑4pm 30min Lunch

Brier Clinic, San Bernardino, CA

• Manage assigned chronic disease panel (diabetes, hypertension, etc.) by developing, implementing, and continuously adjusting individualized care plans to improve clinical outcomes.
• Conduct proactive telephonic and campaign‑based outreach to assess patient needs, address care gaps, and ensure timely completion of labs, screenings, and follow‑up care.
• Provide clinical education and behavior‑change coaching to support medication adherence, self‑management, and lifestyle modification using evidence‑based practices.
• Leverage data analytics and risk stratification tools to identify high‑risk patients, prioritize outreach, and monitor performance against quality measures (e.g., UDS, value‑based metrics).
• Coordinate care across interdisciplinary teams, including providers, care management, pharmacy, and community resources, to ensure continuity and comprehensive patient support.
• Facilitate referrals and transitions of care, including post‑hospital or ED follow‑up, to reduce gaps in care and prevent avoidable utilization.
• Participate in triage and cross‑coverage activities to support patient access, respond to clinical needs, and maintain efficient departmental operations.

• Education:
  
  Bachelor's degree in Nursing preferred.
• Licensure/Certification:
  Current and unrestricted California Registered Nursing License, Basic Life Support (BLS), and CPR certification required. EPIC certification for the module you have been hired into is required. Certified Diabetes Care and Education Specialist (CDCES), Certified Case Manager (CCM) or Accredited Case Manager (ACM) is preferred.
• Experience:
  
  Minimum of three (3) years of clinical nursing experience at the RN level in ambulatory, primary care, or chronic disease management is required. Prior experience working in an FQHC or community health setting with a background in Care Management, Population Health, or Chronic Disease Management, and with a diverse and underserved population is preferred. Experience with UDS/HEDIS measures and patient registries within a performance‑driven environment is preferred.
• Essential Technical/Motor
  
  Skills:
  
  Computer competency; ability to read, write legibly, speak in English with professional quality; use computer, printer, and relevant software.
• Interpersonal
  
  Skills:
  
  Professional and strong communication skills in difficult situations, ability to de‑escalate concerns, telephone etiquette required, ability to translate medical information, effective communication, team‑oriented.
• Essential Mental Abilities:
  Work independently and in teams; analyze data and…