Population Health Nurse

Company : West River Health Services

Job Description - Population Health Nurse

Position Summary:
The Population Health Nurse will promote effective partnerships between patients, families, nurses, physicians and other healthcare disciplines to coordinate care for patients with chronic disease and effectively manage care transitions to facilitate a “shared goal model”. The nurse will partner with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness. The nurse will provide effective clinical health-coaching to assist patients with self-management of their chronic diseases and life-style changes to mitigate health risk.

Excellence in Practice

Provide a coordinated, strategic approach to identify new or manage an established chronically ill patient population.
Stratify patient population according to risk to effectively and efficiently manage patients. Determine frequency of need for provider appointments and CCM encounters. Maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
Implement effective internal tracking systems for patients such as annual wellness visit scheduling, transition of care follow-up calls/timely provider visits and CCM non-face-to-face monthly encounters. Ensure that patient records are reviewed to identify care gaps prior to visit. Post reminders to ensure that all co-morbidities are discussed and documented during the AWV.
Ensure all required elements are documented for CCM and related AWV component billing.
In collaboration with the physician or qualified healthcare provider, develop a care plan based on mutual goals with the patient, family, medical summary and ongoing action plan as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion and facilitate changes as needed.
Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider.
Provide clinical health coaching interventions to motivate patients and families toward successful self-management of chronic disease. Effectively partner with provider practice team members to mobilize needed community resources for the patient and family.
Identify and refer patients to counseling services/resources within the practice to assist with obesity, tobacco cessation, fall prevention, diabetes prevention/management, depression, anxiety and managing cardiovascular disease.
Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, NP, PA and other licensed allied health team members). Provides mentoring/coaching of other practice team members as needed.
Demonstrates understanding in use of EHR resources and patient databases, including Lightbeam and Compass.

Essential Job Requirements:

Education: Registered Nurse program graduate
License Requirements: Current ND or compact state RN licensure. Basic Life Support certification
Experience: Previous experience in caring for chronic disease patients required; Previous experience with care coordination, case management, mobilizing community resources and navigating patients through the healthcare continuum preferred
Possesses strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate to patients with complex medical, emotional and social needs.

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Population Health Nurse

Job Description - Population Health Nurse

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