Population Health Nurse

Melissa Memorial Hospital•Holyoke, CO

3d•Onsite

About The Position

The Population Health Nurse is responsible for the operational aspects and business management of the Family Practice of Holyoke Rural Health Clinic, as well as clinical care and a positive patient service experience. Working with the primary care team, the nurse coordinates annual wellness visits and manages high-risk, chronically ill patients through Chronic Care Management, using health coaching to support self-management and lifestyle changes. The role also includes Transitional Care Management, coordinating with specialty providers, integrating mental and behavioral health services, and mobilizing community resources to help patients navigate healthcare. The nurse supports physicians with patient preparation and examinations, medical histories, vital signs, appointment coordination, special procedures, prescribed medications and injections, patient education, referrals, diagnostic-result communication, and medical records. The role requires recognizing critical patient conditions and responding appropriately, including intervention during emergencies. The nurse also supports clinic care-management programs and tracking systems, participates in Accountable Care Organization initiatives, and contributes to community health and wellness services. Employees are expected to maintain confidentiality, attend reliably, continue professional learning, review and respond to company communications, and perform additional duties as assigned.

Requirements

Associate or bachelor’s degree in nursing.
At least 2 years of experience as an RN in a clinical setting.
Basic Life Support (BLS) is required.
Skills in analysis, organization, multitasking, communication, collaboration, relationship building, critical thinking, problem solving, computer use, and scheduling.

Nice To Haves

Previous Home Health or Hospice experience.

Responsibilities

Participate in the Family Practice of Holyoke’s Accountable Care Organization initiatives, including trainings, meetings, certifications, workshops, webinars, road map calls, and cohort calls.
Work with the clinical team to identify care gaps and provide annual wellness visits, counseling and resource services, preventive screenings, and care management services.
Coordinate and manage care for patients enrolled in principal care management, chronic care management, and transitional care management programs.
Develop care plans with patients and the care team, including mutually agreed goals with patients and their families.
Collaborate with practice leaders and supervisors to implement tracking systems for care-management programs, patient panels, annual wellness visits, and care-management services.
Mobilize community resources and help patients navigate healthcare.
Assist physicians by preparing patients and examination rooms, taking medical histories and vital signs, arranging lab and X-ray appointments, and explaining patient preparations.
Assist physicians with special procedures as required and promptly intervene with appropriate action in emergencies.
Carry out physician orders; handle phone calls as directed, including calling in prescriptions and notifying patients of diagnostic testing results.
Administer injections and medications prescribed by physicians.
Provide delegated patient education, complete physical forms, arrange referrals, and help maintain medical records according to office procedures.
Use observation and assessment skills to distinguish critical from non-critical patient conditions and initiate appropriate procedures.
Handle and store office medications properly.
Provide health and wellness services in the community as needed.
Maintain regular and predictable attendance; continue personal and professional learning; and review, understand, and respond to company email and related correspondence.
Maintain confidentiality, support MMH’s mission and vision, work effectively as part of a team, treat customers with courtesy and compassion, adapt to changing situations, suggest solutions, and report compliance issues.
Perform additional tasks or duties as assigned based on hospital needs.