Population Health Nurse - Timberlyne Family Medicine

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke Primary Care

Pursue your passion for caring with Duke Primary Care, which offers family, adolescent, and internal medicine services as well as urgent, general pediatric, and virtual care at nearly 50 clinic locations across central North Carolina.

Population Health Nurse - Duke Primary Care Timberlyne

The Population Health Nurse plays a transformative role in geriatric care, championing prevention, personalized coordination, and patient empowerment. With a focus on comprehensive assessments and tailored care plans, they ensure seamless transitions and deliver exceptional outcomes. By educating patients, streamlining care, and advocating for evidence-based treatments, these nurses become trusted partners in each patient's healthcare journey. In a collaborative environment, they inspire change, mentor peers, and drive innovation, making a lasting impact on individuals and fostering healthier, thriving communities.

Location : This position is split between two locations : Timberlyne Family Medicine (4 days per week) : 77 Vilcom Center Drive : Suite 200, Chapel Hill NC 27514 and Galloway Ridge Primary Care (1 day per week) : 50 Craggenmore Drive, Pittsboro NC, 27312.

Hours : 8am - 5pm Monday to Friday

What you will do :

The Population Health Nurse is responsible and accountable for clinical expertise for specific complex patient populations.

• Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures.
• Assess the educational needs of the patient / caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community.
• Monitor system access to care, services, and treatment including linkage to the medical home.
• Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
• Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his / her willingness to change, and his / her support to maintain health behavior change.
• Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
• Communicate and coordinate with all provider(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care generally from hospital to home or community facilities.
• Monitor quality and effectiveness of interventions to the population by setting long term and / or short-term specific, measurable goal(s).
• Access and systematically use data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.
• Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence-based care.
• Facilitate Quality Improvement activities that educate, support, and monitor provider(s), regarding evidence-based care for best practice / National Standards of Care (Adapted from CMSA, 2010).
• Utilize innovative nursing and population management tactics to support health throughout the continuum of care to promote quality, cost-effective outcomes.
• Participate in quality / performance improvement programs and projects, product evaluation, outcomes evaluation studies and / or clinical research.
• Provide clinical experience in a preceptor role for students attending institutions that have contractual agreements with DUHS. Participate in the orientation of new nursing staff and provide expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff.
• This position may require home visits; however, position specific details and duties are available upon request.
• The work activity and patient acuity levels can create a stressful atmosphere.

What you will need : Education

Experience

Degrees, Licensure, and / or Certification

Knowledge, Skills, and Abilities

The work activity and patient acuity levels can create a stressful atmosphere; therefore, individuals successful in this job are :

Job Title : POPULATION HEALTH NURSE

Job Code : 5555

FLSA : E

Job Level : G1

Revised Date : 05 / 01 / 2024

Supervisory Responsibility : No

Duke University is an Affirmative Action / Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and / or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

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