RN - Population Health - FT - Days - MHS

Memorial Healthcare

About The Position

Under the direction of the Population Health Management leadership, the Population Health Registered Nurse (PHRN) serves as a liaison between the Memorial Healthcare System (MHS), Memorial Health Network (MHN), Broward Guardian, ACHN, Memorial Physician Group (MPG), community providers, post-acute care facilities, external healthcare organizations, and the patient. The PHRN follows nursing processes and protocols and implements systems of care that facilitate care coordination and close monitoring of specially defined, high and rising risk patient populations attributed to value-based programs or MHA. The PHRN fosters an inter-professional team-based approach ensuring continuity of care extends beyond the acute care boundaries. The PHRN roles can include a focus on care management, quality, post-acute transitions, remote patient monitoring, care coordination or all of the above.

Requirements

Associates: Nursing (Required)
Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate
Registered Nurse License (RN LICENSE) - State of Florida (FL)
Three (3) years of healthcare experience.
Excellent written and oral skills, with the ability to engage, inspire, build credibility and trust with peers and patients.
Collaborative working style with the ability to work across different teams, areas of expertise, and adapt to various environments and clientele.
Highly organized and self-motivated individual with ability to adapt to various assignments and ability to work autonomously.

Nice To Haves

Bachelor of Science in Nursing (preferred)

Responsibilities

Establishes, maintains, and enhances relationships with post-acute care facilities and providers.
Serves in an expanded healthcare role to collaborate with inter-professional colleagues, post-acute facilities, and patients/families to ensure care coordination, close monitoring, and readmission prevention for specially defined high and rising risk patient populations promoting quality and efficiency in the delivery of health care across multiple care settings.
Performs concurrent medical record review using specific indicators and criteria.
Monitors the quality, frequency, and appropriateness of healthcare delivery by post-acute providers and reports variations of plan of care, health status, or psychosocial issues to PCP and appropriate members of the care team.
Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in coordination of care across the healthcare continuum.
Provides complex care/case management including acute/chronic illness-oriented assessment and monitoring, medication therapy management in collaboration with the transitions of care pharmacy team monitoring, health education and self-care management.
Integrates evidence-based clinical guidelines, patient and family centered care plans and protocols to promote the highest quality of healthcare delivery for a defined complex, high-risk patient population.
Responsible for reviewing and co-signing modification of care plans by the Population Health Clinical Care Coordinator and Population Health Nurse.
Guides and supports clinical decision making to Population Health Clinical Coordinator and Population Health Nurse for a defined low to moderate risk patient population.
Provide support for the Innovative Placement Program as needed.
Provides transitional care management and coordination of care for patients recently discharged from the acute care setting in collaboration with patients, family members, post-acute providers, internal and external healthcare organizations/team members and post-acute facilities.
Conducts initial health risk assessment, identifies, and manages health and safety risks including social determinants of health, functional status, cognitive ability, medication clarification, and health literacy.
Develops a patient-centered care plan to optimize disease management.
As appropriate, discusses plan of care with patients and families.
Assesses patient/caregiver capacity and willingness to participate in care model program.
Responsible for interpreting and providing appropriate interventions to automated alerts and notifications in remote patient monitoring.
Will coordinate with providers to assure appropriate follow up for the patient under the provider’s direction.
Supports, participates, and coordinates activities for the preparation and completion of audits, chart reviews, quality reporting and regulatory reviews.
Collaborates with the clinical leadership and business intelligence teams to track clinical performance and interventions that support clinical and administrative outcomes, as applicable.