What are the responsibilities and job description for the Population Health Nurse position at Goshen Medical Center?
Population Health Nurse
The Population Health Nurse is responsible and accountable for clinical expertise for specific complex patient populations. This role will perform, assessment of disease states and utilization, disease management, care plan development and facilitation, referral to appropriate levels of care, etc. The Population Health Nurse functions as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, families, communities or entire demographic.
Essential Duties and Responsibilities:
1.
Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures.
2.
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.
3.
Address the total individual, inclusive of medical, psychosocial, behavioral, and emotional needs.
4.
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.
5.
Communicating and coordinating with all providers 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.
6.
Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
7.
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.
8.
Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence-based care.
9.
Utilize innovative nursing and population management tactics to support health throughout the continuum of care in order to promote quality, cost-effective outcome. Participate in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research.
10.
Coordinates and monitors services, including comprehensive tracking of patient’s compliance in relation to care plan objectives.
11.
Establish professional working relationships with patients, visitors, staff, and providers effectively communicating Goshen Medical Center’s mission.
12.
Establish therapeutic relationship with patients from initial identification through closure.
13.
Maintain accurate knowledge of available community resources.
14.
Assist with care gap identification and closure as directed by Coordinator of Clinical Quality and Compliance.
15.
Other duties as assigned.
Required Qualifications: Education/Experience
1.
Current RN licensure in the state of North Carolina required.
2.
Three years of nursing experience required.
3.
Experience working in a multicultural setting.
4.
Strong use of computer software tools and data files.
5.
Ability to develop and maintain positive relationships with staff, community resources, and other organizations.
6.
Proficient in review of medical records and other patient care information.
7.
Understanding of and sensitivity to the at-risk community.
8.
Good communication skills, such as listening, speaking, and writing.
9.
Ability and willingness to provide emotional support, encouragement, and motivation to patients.
10.
Ability to work independently, be a self-starter and comfortable with continuous change.
11.
Performs other duties as required or assigned which are reasonably within the scope of the duties in this job classification .
12.
Certain jobs at Goshen Medical Center 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.Desired Qualifications: Education/Experience
1.
BSN preferred
2.
Oral and written fluency in English and Spanish.
