Population Health Nurse (RN) - East Austin

Harbor Health looking for a collaborative Registered Nurse to become a member of our team! Harbor Health is an entirely new multi-specialty clinic group in Austin, TX utilizing a modern approach to co-create health with those who get, give, and pay for it, allowing everyone to fully flourish. Join us as we build a fully integrated system that connects care to a better payment model that truly puts the human being at the center.

The Registered Nurse will coordinate team-based care to provide health services to members, through effective partnerships with clients, their caregivers/families, community resources, and their primary provider. RNs will facilitate a shared goal model within and across settings to achieve coordinated high-quality care that is centered on the clients' healthcare and health goals.

Our Registered Nurses will be responsible for managing the care coordination of a panel of clients through the following:

• Use of coaches for basic care coordination.
• Direct communication with clients for intermediate care coordination.
• Escalated care coordination to provider.
• Assume some “on-call” for after-hour triage.
• Provide mentoring/coaching of other population health and care coordination team members and coach clients and families toward successful self-management of their chronic disease.
• Utilize tools and documents that support a guided care process, collaborate with clients and families toward an effective plan of care.
• Assess client and family’s unmet health and social needs.
• Provide effective communication to improve health literacy.
• Develop a care plan based on mutual goals with client, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor client’s adherence to plan of care and progress toward goals in a timely fashion, facilitate changes as needed.
• Create ongoing processes for clients and families to determine and request the level of care coordination support they desire over time.
• Facilitate client access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator)
• Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow up, and integration of information into the care plan regarding transitions-in-care and referrals.
• Serve as a point of contact, advocate, and informational resource for client, family, care team, payers, and community resources and facilitate and attend meetings between client, families, care team, payers, and community resources, as needed.
• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Develop systems to prevent errors (e.g., effective medication reconciliation and shared medical records).
• Perform regular visits (via telemedicine) to provide client and family support and education.
• Perform other duties as assigned.

Successful RNs will have:

• Bachelor's Degree from accredited University in Nursing
• Current licensure as an RN to practice in the State of Texas by the State Boards without restrictions
• Current CPR certification required
• Valid Texas Driver’s License
• Minimum 1 year of experience as a Registered Nurse
• Computer skills with the ability to enter information in the E.H.R. system and compile reports or data as requested
• Ability to read, write, and speak English
• Skill in providing excellent customer service and support; organizing and prioritizing workload and meeting deadlines; and excellent written and verbal communication
• Ability to interact effectively and professionally with persons from diverse cultural, socioeconomic, education, racial, ethnic, and professional backgrounds
• Ability to work effectively with managers, co-workers, members of the public and professional groups
• Ability to communicate effectively, clearly, concisely with others (internal and external customers, both verbally and in writing), consistently demonstrate positive/proactive customer service attitude
• Consistently maintains ethical behaviors exemplary of quality public service and fair standards, inclusively, among all employees and members of the public
• Ability to work as an effective team member; function independently, exercise sound judgment and initiative; be flexible to shift priorities; maintain confidentiality; establish and maintain effective interpersonal work relationships, and effectively assist other providers.

• Additional Skills & Experiences Preferred include:

• Bilingual English/Spanish
• Experience with Phlebotomy
• BLS Certification

Additional Skills & Experiences Preferred include:

• Bilingual English/Spanish
• Experience with Phlebotomy
• BLS Certification

Physical Requirements of the role include:

• Working irregular hours
• Physically demanding, moderate-stress environment
• Exposure to blood and body fluids, communicable diseases, chemicals, radiation, and repetitive motions
• Pushing and pulling heavy objects
• Full range of body motion including handling and lifting clients
• Position requires light to moderate work with 50 pounds maximum weight to lift and carry
• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing

If you are passionate about health care and you want to create something new together, we want you to be apart of our team!

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