Population Health Nurse (PHN) - Duke Primary Care Pickett Road

Duke Careers•Durham, NC

16d•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 - Duke Primary Care Pickett Road Duke University Health System seeks to hire an experienced Registered Nurse who will embrace our mission of Advancing Health Together. Department Profile: Duke Primary Care Pickett Road is a patient-centered primary care clinic providing comprehensive healthcare services to individuals and families in the Durham, NC, area. Serving a diverse patient population, including adults, seniors, and adolescents, the clinic offers a wide range of services, including preventive care, chronic disease management, acute illness treatment, women's health, and on-site diagnostic testing. As part of the Duke Health network, the clinic is committed to delivering high-quality, evidence-based medical care with a focus on patient-centered treatment, health education, and seamless coordination with Duke Health specialists when advanced care is needed. Location: 3004 Tower Boulevard, Durham, NC 27707 Hours: 8am – 5pm Monday – Friday What you will do: The Population Health Nurse partners with pediatric patients with complex health needs, delivering care and education through a dynamic blend of educational telehealth visits and care coordination. This role guides children and their families in managing chronic illnesses, develops and coordinates individualized care plans, and ensures connection to the right resources and support. As an integral member of an interdisciplinary team, the nurse helps families navigate care transitions, empowers them with knowledge and tools, and drives improved, patient-centered health outcomes.

Requirements

BSN
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

Nice To Haves

Pediatric experience preferred

Responsibilities

Deliver specialized nursing care, create individualized care plans, and educate patients and families while using clinical judgment and following established policies.
Identify the educational needs of patients and caregivers related to their condition, recovery, and transition back to home and community life.
Ensure patients have access to the right care, services, and resources, including coordination with their medical home.
Address the whole person — medical, emotional, behavioral, psychosocial, and spiritual needs — for truly comprehensive care.
Actively involve patients and their support systems in decision-making, using a collaborative approach to build self-management skills and encourage long-term healthy behaviors.
Communicate and coordinate with providers and care team members to reduce gaps in care, especially during transitions like hospital-to-home.
Set measurable goals for patients and monitor the quality and success of interventions over time.
Use data from medical records, claims, and program reports to identify patients who need outreach, education, and additional support.
Advocate for patients and work closely with providers to ensure care is evidence-based and aligned with national standards.
Support quality improvement initiatives by educating providers, tracking outcomes, and helping implement best practices.
Apply innovative population health strategies to improve health outcomes and keep care cost-effective.
Participate in performance improvement projects, product evaluations, and clinical research to advance patient care.
Serve as a preceptor and mentor for nursing students and new staff, providing guidance and coaching in both formal and informal settings.
May perform home visits as needed (specific details provided by the department).
Manage the demands of a fast-paced, high-acuity environment with professionalism and resilience.