Population Health RN

Good Samaritan • Vincennes, IN

1d

About The Position

The Population Health Nurse will work in collaboration with primary care providers and healthcare teams. Primary responsibilities will include identifying Medicare patients appropriate for Annual Wellness Visits and executing guided processes to complete the visit. The role also involves effectively coordinating and managing high-risk chronically ill patients through Chronic Care Management and Remote Patient Monitoring, utilizing health coaching techniques to assist patients with self-management of their chronic diseases and lifestyle changes to mitigate health risk. Additionally, the nurse will initiate Transitional Care Management coordinating efforts with post-acute providers (Home Health, PCP, Pharmacy, SNF etc.).

Requirements

• Identification of Medicare patients appropriate for Annual Wellness Visits & execute guided processes to complete the visit.
• Effectively coordinate & manage high-risk chronically ill patients through Chronic Care Management & Remote Patient Monitoring utilizing health coaching techniques to assist patients with self-management of their chronic diseases & lifestyle changes to mitigate health risk.
• Initiate Transitional Care Management coordinating efforts with post-acute providers (Home Health, PCP, Pharmacy, SNF etc.).
• Advanced health coach certification (implied by training attendance)
• Experience with Chronic Care Management (CCM)
• Experience with Remote Patient Monitoring (RPM)
• Health coaching techniques
• Ability to assist patients with self-management of chronic diseases and lifestyle changes
• Experience with Transitional Care Management
• Collaboration with primary care providers and healthcare teams
• Ability to stratify patient population according to risk score
• Ability to develop care plans based on mutual goals with patient and family
• Ability to monitor patient adherence to care plan and progress toward goals
• Experience implementing internal tracking systems for patients (patient panels, AWV scheduling, transition of care follow-up, CCM encounters, RPM navigation)

Responsibilities

• Attend and actively participate in all ACO population health related trainings and meetings including advanced health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on-one meetings, as needed.
• Works collaboratively with the ACO team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the provider; post reminders to secure that all co-morbidities are discussed and documented during AWV.
• Attend and actively participate in all Value Based Contract meetings, trainings & patient outreach.
• Stratify patient population according to risk score. Effectively and efficiently manage patients with multiple chronic diseases; Identify patients appropriate for Chronic Care Management (CCM). In collaboration with the PCP, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
• Ensure sharing of positive patient stories or compliments involving care team efforts.
• Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/visits, CCM encounters, navigate care for patients enrolled in RPM.
• CMA oversight as directed by Quality & Care Coordination Manager.
• Perform other related duties as directed by Quality & Care Coordination Manager & Executive Director, Good Samaritan Physician Network.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed