Population Health Nurse

Melissa Memorial Hospital•Holyoke, CO

4d•$35 - $45•Onsite

About The Position

The Population Health Nurse is responsible for operational and business management activities for the Family Practice of Holyoke Rural Health Clinic, as well as clinical care and a high-quality patient service experience. Working with the primary care team, the nurse coordinates annual wellness visits and supports high-risk patients with chronic conditions through care management and health coaching. The role also supports transitional care management, coordination with specialty providers, and integration of mental and behavioral health services. The nurse participates in the clinic’s Accountable Care Organization initiatives and helps identify patients who need wellness visits, preventive screenings, counseling, resource services, and care management. The position develops care plans with patients, families, and the care team; coordinates care-management programs; and helps implement systems for tracking patients, panels, and visits. The nurse also navigates patients to community and health care resources. In the clinic, the nurse assists physicians by preparing patients and examination rooms, obtaining medical histories and vital signs, arranging laboratory and imaging appointments, explaining preparation instructions, and assisting with special procedures. Other clinical duties include carrying out physician orders, responding to calls as directed, relaying diagnostic test results, administering prescribed medications and injections, providing delegated patient education, completing forms and referrals, maintaining medical records, and properly handling and storing medications. The nurse must recognize critical changes in patient condition and take appropriate action, including promptly intervening in emergencies. Regular, predictable attendance and ongoing personal and professional learning are expected. Additional duties may be assigned based on hospital needs.

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.
Analytical, organized, and able to multitask.
Excellent communication and collaboration skills; able to build relationships.
Critical thinking and problem-solving skills.
Computer skills and scheduling experience.

Nice To Haves

Previous Home Health or Hospice experience.

Responsibilities

Coordinate annual wellness visits and provide counseling, preventive screenings, resource services, and care management.
Manage care for patients enrolled in principal care management, chronic care management, and transitional care management programs.
Use health coaching to help patients manage chronic conditions and make lifestyle changes to reduce health risks.
Develop care plans with patients, the care team, and patients’ families, including shared goals.
Coordinate care with specialty providers and support integration of mental and behavioral health services.
Participate in the Family Practice of Holyoke’s Accountable Care Organization initiatives, including trainings, meetings, certifications, workshops, webinars, and calls.
Collaborate with practice leaders and supervisors to implement tracking systems for care-management programs, patient panels, and wellness visits.
Mobilize community resources and help patients navigate health care.
Assist physicians by preparing patients and examination rooms, obtaining medical histories and vital signs, arranging lab and X-ray appointments, and explaining preparation instructions.
Assist with special procedures and promptly intervene with appropriate action in emergencies.
Carry out physician orders; handle calls as directed, including calling in prescriptions and notifying patients of diagnostic testing results.
Administer physician-prescribed injections and medications and ensure medications are properly handled and stored.
Provide delegated patient education, complete physical forms, arrange referrals, and maintain medical records according to office procedures.
Use observation and assessment skills to distinguish critical from non-critical patient conditions and initiate appropriate procedures.
Maintain regular and predictable attendance, continue personal and professional learning, and review and respond to company email and related correspondence.
Support the hospital’s mission and values, maintain confidentiality, collaborate with the team, treat customers respectfully, adapt to changing situations, suggest solutions, and report compliance issues.
Perform additional duties as assigned based on hospital needs.