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

As well as 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.
• Communicating and coordinating 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).
• Accessing and systematically using 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. Participates in the orientation of new nursing staff and provides 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

• BSN

Experience

• 3 years of nursing experience required

Degrees, Licensure, and/or Certification

• Current RN licensure in the state of North Carolina required.

Knowledge, Skills, and Abilities

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

• Organized and motivated by a fast-paced environment
• Able to manage multiple tasks/projects simultaneously
• Proficient in review and assess needs quickly
• Strong with the use of computer software tools and data files
• Comfortable with continuous change and self-initiating
• Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics)
• Distinguishing Characteristics of this Level
• Additional job expectations include the ability to: -- Maintain strict confidentiality
• Promote programs and services to community
• Build effective and trusting relationships with patient/peers
• Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests
• Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions
• Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate
• Use data to analyze trends and to verify data
• Self-directed and able to organize and manage multiple tasks/projects simultaneously
• Ability to promote programs and services to community
• Proficient in review of medical records and other patient care information