Population Health Nurse (RN) - Duke Primary Care Louisburg

Duke Careers

8d•Onsite

About The Position

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together. About Duke Primary Care Pursue your passion for caring with Duke Primary Care, which offers family, adolescent, and internal medicine services as well as urgent, general pediatric, and virtual care at nearly 50 clinic locations across central North Carolina. Duke Nursing Highlights: Duke University Health System is designated as a Magnet organizationNurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses. Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification. Duke University Health System has 6000 + registered nurses Quality of Life: Living in the Triangle! Relocation Assistance (based on eligibility) Population Health Nurse (RN) - Duke Primary Care Louisburg Duke Primary Care Louisburg offers compassionate, comprehensive care for the whole family in a welcoming community setting. Our experienced team of family medicine physicians and nurse practitioners cares for patients ages 6 and older, partnering with you to support your health at every stage of life. From annual physicals and preventive screenings to same-day sick visits for colds, flu, and sinus infections, we’re here when you need us most. We also provide immunizations, sports physicals, and ongoing management of chronic conditions like high blood pressure and high cholesterol. With convenient weekday hours and same-day appointment availability, Duke Primary Care Louisburg makes it easier to stay healthy and feel your best. Location: 205 Sandalwood Ave, Suite C, Louisburg, NC 27549 Hours: 8am – 5pm Monday to Friday What you will do: The Population Health Nurse plays a key role in improving geriatric care through prevention, comprehensive assessments, and personalized care coordination. They support smooth transitions across care settings, educate and advocate for patients, and collaborate closely with care teams to deliver evidence-based, patient-centered outcomes that strengthen individual and community health. Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures. Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community. Monitor system access to care, services, and treatment including linkage to the medical home. Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process. Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change. Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness. Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care generally from hospital to home or community facilities. Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s). Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention. Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence-based care. Facilitate Quality Improvement activities that educate, support, and monitor provider(s), regarding evidence-based care for best practice/National Standards of Care (Adapted from CMSA, 2010). Utilize innovative nursing and population management tactics to support health throughout the continuum of care to promote quality, cost-effective outcomes. Participate in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research. Provide clinical experience in a preceptor role for students attending institutions that have contractual agreements with DUHS. Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff. This position may require home visits however; position specific details and duties are available upon request. The work activity and patient acuity levels can create a stressful atmosphere.

Requirements

BSN required
3 years of nursing experience required
Current RN licensure in the state of North Carolina required.
Organized and motivated by a fast-paced environment
Able to manage multiple tasks/projects simultaneously
Proficient in review and assess needs quickly
Strong with the use of computer software tools and data files
Comfortable with continuous change and self-initiating
Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics)
Maintain strict confidentiality
Promote programs and services to community
Build effective and trusting relationships with patient/peers
Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests
Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions
Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate
Use data to analyze trends and to verify data
Self-directed and able to organize and manage multiple tasks/projects simultaneously
Ability to promote programs and services to community
Proficient in review of medical records and other patient care information

Responsibilities

Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures.
Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community.
Monitor system access to care, services, and treatment including linkage to the medical home.
Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care generally from hospital to home or community facilities.
Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.
Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence-based care.
Facilitate Quality Improvement activities that educate, support, and monitor provider(s), regarding evidence-based care for best practice/National Standards of Care (Adapted from CMSA, 2010).
Utilize innovative nursing and population management tactics to support health throughout the continuum of care to promote quality, cost-effective outcomes.
Participate in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research.
Provide clinical experience in a preceptor role for students attending institutions that have contractual agreements with DUHS. Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff.
This position may require home visits however; position specific details and duties are available upon request.