Population Health Nurse

Melissa Memorial Hospital•Holyoke, CO

11d•$30 - $40•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 the clinical care of patients and excellence in their service experience. The Population Health Nurse will work with the primary care team. Primary responsibilities include coordinating annual wellness visits and manage high risk chronically ill patients through Chronic Care Management utilizing health coaching techniques to assist patients with self-management of their chronic diseases and life-style changes to mitigate health risk. The population health nurse is also responsible for Transitional Care Management, coordinating care efforts with specialty providers and integrating mental and behavioral health services. Exhibits behaviors that are consistent with the Mission, and Values of Melissa Memorial Hospital and the culture and objectives of MMH. All employees are expected to work as needed in providing health and wellness services in the community.

Requirements

MINIMUM Required education: Associates or bachelor’s degree in nursing.
2 years minimum experience as an RN in a clinical setting.
Skills: Analytical, organized, multitasked, excellent communicator, collaborative, relationship building, critical thinking, problem solving, computer skills, and scheduling experience.

Nice To Haves

PREFERRED 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, cohort calls, and other objectives.
Identify care caps with clinical team to provide annual wellness visits, counseling/resource services, preventative 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 to help manage chronic conditions. Care plans to include mutual goals with the care team, patient, and the patient’s family.
Collaborate with practice leaders/supervisors to implement tracking systems for care management programs, patient panels, annual wellness visits, principal care management, chronic care management, and transitional care management.
The Population Health Nurse will mobilize community resources and navigate patients through healthcare.
The Population Health Nurse assists the Physician with patients, including preparing patients and he examination rooms; taking initial medical history for the chart, taking vital signs, making lab and x-ray appointments, and explaining the preparations to the patients.
In addition, assists the Physician in all special procedures, as required.
This position will promptly intervene with appropriate action in an emergency. Basic Life Support (BLS) is required.
The Population Health Nurse carries out physician order.
This position handles phone calls as directed by the physician, such as calling in prescriptions, and notifies patients of diagnostic testing results.
This incumbent gives injections and medications prescribed by the physician.
The Population Health Nurse is responsible for providing patient education as delegated, completing physical forms and referral arrangements, and assists in maintaining a large volume and variety of medical records in accordance to office procedures.
The Population Health Nurse must be able to incorporate observation and assessment skills and differentiate between critical and non-critical patient conditions to initiate appropriate procedures.
The Population Health Nurse is responsible for proper handling and storage of all mediations stored in the office.
Regular and predictable attendance.
Continuous learning in both personal and professional development.
Consistent review, comprehension and reply of company email and related correspondence.
To include additional tasks or other duties as assigned.