Population Health Nurse
Population Health Nurse
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Salary Not Disclosed
1 Vacancy
Job Description
Coordinates teambased care provide health services to individuals through effective partnerships with patients their caregivers/families community resources and their physician. Facilities a shared goal model within and across settings to achieve coordinated highquality care that is patient and familycentered.
Responsibilities:
- Provide a coordinated strategic approach to detect early and manage effectively the chronically ill patient population.
- Collaborate with in patient case management as appropriate.
- Coordinate with the inpatient case manager as it relates to the QHC Readmission Transition of Care Scope of Work.
- Implement an effective internal tracking system for identified patients.
- Coach patients/families toward successful selfmanagement of their chronic disease.
- Utilize tools and documents that support a guided care process collaborate with patient/family toward an effective plan of care.
- Assess patient and familys unmet health and social needs.
- Provide effective communications to improve health literacy.
- Develop a care plan based on mutual goals with the patient family and providers emergency plan medical summary and ongoing action plan as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion and facilitate changes as needed.
- Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
- Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
- Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator).
- Cultivate and support primary care and subspecialty comanagement with timely communication inquiry followup and integration of information into the care plan regarding transitionsincare and referrals.
- Serve as the contactpoint advocate and informational resource for patient family care team payers and community resources.
- Ensure effective tracking of test results medication management and adherence to followup appointments.
- Develop systems to prevent errors (e.g. effective medication reconciliation and shared medical records).
- Facilitate and attend meetings between patient families care team payers and community resources as needed.
- Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach certification quarterly Regional Workshops monthly cohort calls with other NRACO Care Coordinators and Coach).
Requirements:
- Licensure as a Registered Nurse in the state of IL required.
- BSN or higher degree preferred.
- 35 years experience in clinical or community health settings preferred.
Employment Type
Full-Time
