Population Health Nurse

Hillsdale Hospital•Hillsdale, MI

4d•Onsite

About The Position

Provides a coordinated, strategic approach to detect early and manage effectively the chronically and/or mentally fragile patient population. Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care. Assesses patient and family’s unmet health and social needs Provides effective communications to improve health literacy for patients/families Coaches patients/families towards successful self-management of their chronic disease Acts as liaison between PCP and Specialists on patient condition as needed between office visits Develops a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan Monitors patient adherence to plan of care and progress toward goals in a timely fashion, and facilitates changes as needed Creates ongoing processes for patients/families to determine and request the level of care coordination support they desire Promotes healthy behaviors in all populations and ensures navigation assistance with community resources Assists in outreach to patients made after they have been seen in ED or inpatient stay as necessary. Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator) Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources. Enrolls patient in Medicaid and assists with other community resource referrals when applicable. Ensures effective tracking of test results, medication management, and adherence to follow-up appointments Facilitates and attends meetings between patient, families, care team, payers, and community resources Ensures all VBR and MSSP metrics are met. Assists with VFC (Vaccines for Children) immunization programming at current Primary Care sites. Performs other duties as required or assigned.

Requirements

Current Michigan licensure as an RN or LPN minimum
Previous experience in caring for chronic disease patients required
Must be proficient in communication and computer technologies (email, cell phone, etc.)
Previous experience with health IT systems, ERMs and data reports

Nice To Haves

Prefer experience in clinical or community health, care coordination, case management, home health or behavioral health
Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers if needed

Responsibilities

Provides a coordinated, strategic approach to detect early and manage effectively the chronically and/or mentally fragile patient population.
Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care.
Assesses patient and family’s unmet health and social needs
Provides effective communications to improve health literacy for patients/families
Coaches patients/families towards successful self-management of their chronic disease
Acts as liaison between PCP and Specialists on patient condition as needed between office visits
Develops a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan
Monitors patient adherence to plan of care and progress toward goals in a timely fashion, and facilitates changes as needed
Creates ongoing processes for patients/families to determine and request the level of care coordination support they desire
Promotes healthy behaviors in all populations and ensures navigation assistance with community resources
Assists in outreach to patients made after they have been seen in ED or inpatient stay as necessary.
Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator)
Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
Enrolls patient in Medicaid and assists with other community resource referrals when applicable.
Ensures effective tracking of test results, medication management, and adherence to follow-up appointments
Facilitates and attends meetings between patient, families, care team, payers, and community resources
Ensures all VBR and MSSP metrics are met.
Assists with VFC (Vaccines for Children) immunization programming at current Primary Care sites.
Performs other duties as required or assigned.