Population Health Nurse

Southwest Community Health Center Inc•Bridgeport, CT

6d•Onsite

About The Position

The Population Health Nurse works to improve health outcomes by focusing attention on groups of patients as well as individual patients identified as having or likely to have gaps in care, chronic conditions, adverse health outcomes, or other factors that may affect access to and outcomes of care. The individual performs various job functions designed to improve patient engagement, quality of care, efficiency in the delivery of care, and optimal resource management. The Population Health Nurse will work directly with the Chief Medical Informatics Officer and will work collaboratively with patients, cross functional teams, Quality Assistants, and the Senior Management Team in the support of quality program needs and strategic initiatives. This position supports specific contractual and program related requirements and value-based care initiatives.

Requirements

Strong communication, interpersonal, and organizational skills.
Excellent computer skills including Microsoft Office (Word, Excel).
Demonstrated knowledge of EHR systems preferred.
Demonstrated ability to work independently and in a team environment.
CPR/BLS Certified.
RN/BSN OR RN/AA or LPN with a minimum of one year of case management, care coordination, or chronic care management experience.

Nice To Haves

Bilingual and/or Multilingual in English and Spanish.
Minimum of one (1) year experience in a setting that focuses on medically complex patients.
Experience in a care-related quality role.

Responsibilities

Utilizes reports and population health tools to identify patients for outreach and targeted interventions.
Performs chronic care management for identified, high risk populations, including management of patients with multiple co-morbidities or high risk for readmission to hospital setting.
Engages patients in care coordination, either directly or through referral and coordination with other members of the care team.
Facilitates and tracks identification of patients for Chronic Care Management (CCM) services.
Engages patients and performs and documents care management activities according to CCM program requirements.
Performs Annual Wellness Visits (AWVs) and required screenings.
Facilitates and tracks provider completion of AWVs.
Works collaboratively with provider and care team to ensure care gaps are closed and documentation requirements for quality reporting and chronic conditions coding are met.
Facilitates the coordination of care between health care services, including hospital/ED care transitions.
Ensures continued follow up care and ongoing care management as needed.
Leads patient engagement initiatives for telehealth programs (e.g., remote monitoring) focused on engaging high-risk populations.
Regularly performs clinical services (e.g., screenings, point of care testing, Retinavue) to close gaps in care.
Conducts patient education as needed to advance self-management behaviors.
Performs clinical auditing and data entry tasks for reporting of key metrics to internal and external stakeholders.
Prepares reports on outcomes of population health initiatives.
Provides staff education.
Participate in staff meetings and other activities as needed.
Other related duties as assigned.