Population Health Float Nurse (LPN)

Kintegra Health•Gastonia, NC

11d•Remote

About The Position

Under the direct supervision of the Population Health Manager, the Population Health Float Nurse works collaboratively with providers, clinical support staff, and other healthcare professionals to deliver a medical home model and optimize care using a team-based approach. This role is integral to the care team and is responsible for prioritizing daily interventions based on required services for patients on provider panels. The nurse engages patients and families dealing with chronic diseases and complex medical conditions, helping them develop individualized goals to enhance self-management. Responsibilities include chronic care management, care plan development, care coordination, and connecting patients to internal and community resources. The nurse will communicate extensively with interdisciplinary team members within the organization and with external community and contractual partners. Work will be guided by established quality benchmarks and clinical practices, including but not limited to Uniform Data System (UDS), Patient-Centered Medical Home (PCMH), and Healthcare Effectiveness Data and Information Set (HEDIS).

Requirements

Excellent verbal communication
Ability to adapt to changing priorities
Strong organizational, problem-solving, and critical thinking skills
Proficiency in Microsoft Office Suite
Understanding of quality improvement (QI) methodologies
Proficiency in EMR documentation and electronic chart review
Minimum of three (3) years in a public health or ambulatory care setting
Licensed Practical Nurse (LPN) or Registered Nurse (RN)
Unrestricted license in the state of North Carolina (if applicable)
Current BLS certification

Responsibilities

Conduct pre-visit panel assessments to support care team communication and service delivery during scheduled encounters (e.g., huddles, pre-visit planning, recalls, follow-ups)
Monitor daily patient schedules to assess availability and triage walk-ins
Provide telephonic triage during business hours and patient education using evidence-based criteria within scope of practice
Coordinate quality improvement strategies under the direction of the Practice Manager and QI Champion, in collaboration with the Kintegra Health QI Department
Maintain detailed knowledge of provider roles, support staff functions, and EMR documentation standards to analyze clinical quality reports
Educate new patients on the Medical Home model, Patient Portal, Kintegra Health ancillary services, and the team-based care approach
Serve as a liaison between patients, clinical teams, operations, patient services, and customer care departments
Support medication adherence in collaboration with the Kintegra Pharmacy Team
Complete Health Risk Assessments
Provide Chronic Care Management services, including telephonic outreach and care plan development to support disease management goals
Communicate effectively with providers, interdisciplinary team members, community resources, and contracted partners
Document all care management activities clearly and concisely in the electronic medical record
Attend departmental meetings at assigned sites
Perform other duties as assigned