The Population Health Nurse will promote effective partnerships between patients, families, nurses, physicians, other qualifies healthcare providers and clinical disciplines to coordinate care for patients with chronic disease and effectively manage care transitions to facilitate a "shared goal model". The Population Health Nurse will partner with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness.
Essential Duties & Responsibilities:
-Manages the clinic's Medicare population
-Identifies eligibility
-Performs pre-assessment evaluation
-Completes and tracks annual wellness visits
-Follows up with preventative screening.
-Attends monthly ACO meetings and quarterly Steering Committee meetings.
-Provides effective clinical health coaching to assist the patients with self-management of their chronic disease and life-style changes to mitigate health risks.
-Completes data collection, analysis, and reports in a timely manner.
-Assists with the review of chart audits and data submission for various payors related quality incentive programs.
Education: Vocational/Technical degree in Practical Nursing required.
License/Certification: LPN license and CPR required.
Additional Experience Preferred2 years experience in provider practice or clinical health setting preferredAttention to detail and accuracy in of documentation of records
Previous experience with health IT systems and data reports preferred