Population Health Nurse in Bridgeport, Connecticut at Southwest Community Health Center Inc

Summary: 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.

SPECIFIC DUTIES AND RESPONSIBILITIES: All duties are subject to accommodation in accordance with the Americans with Disabilities Act (ADA):

• 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. 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.

Qualifications:

• 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.
• Strongly Preferred: Bilingual and/or Multilingual in English and Spanish.
• CPR/BLS Certified.

Education and/or Experience:

• RN/BSN OR RN/AA or LPN with a minimum of one year of case. management, care coordination, or chronic care management experience.

Preferred:

• Minimum of one (1) year experience in a setting that focuses on medically complex patients.
• Experience in a care-related quality role.

Physical Requirements and Work Environment:

The physical requirements and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position requires the manual dexterity sufficient to operate phones, computers and other office equipment. The position requires the physical ability to kneel, bend and perform light lifting. This person must have the ability to write and speak clearly using the English language to convey information and be able to hear at normal speaking levels both in person and over the telephone. Specific vision abilities required by this job include close vision, depth perception and the ability to adjust focus. Generally, the working conditions are good with little or no exposure to extremes in health, safety hazards and/or hazardous materials. This person must have the ability to travel as required to work with staff.