Under the direction of the Population Health Management leadership, the Population Health Nurse (PHRN) is considered a nursing lead of a multidisciplinary care team. The PHRN serves as a liaison between the Memorial Healthcare System (MHS), Memorial Health Network (MHN), Memorial Physician Group (MPG), community providers, external healthcare organizations, and patient. The PHRN follows nursing process and implements systems of care that facilitate care coordination and close monitoring of specially defined high and rising risk patient populations. The PHRN fosters an interprofessional team based approach ensuring continuity of care extends beyond the acute-care boundaries.
• Conducts initial health risk assessment, identifies and manages health and safety risks including social determinants of health, functional status, cognitive ability, medication clarification, and health literacy. Develops a patient-centered care plan to optimize disease management. As appropriate, discusses plan of care with patients and families. Assesses patient/caregiver capacity and willingness to participate in care model program.
• Provides complex care/case management including acute/chronic illness oriented assessment and monitoring, medication therapy management in collaboration with the transitions of care pharmacy team monitoring, health education and self-care management. Integrates evidence-based clinical guidelines, patient and family centered care plans and protocols to promote the highest quality of healthcare delivery for a defined complex, high-risk patient population. Responsible for reviewing and co-signing modification of care plans by the Population Health Clinical Care Coordinator and Population Health Nurse I. Guides and supports clinical decision making to Population Health Clinical Coordinator and Population Health Nurse I for a defined low to moderate risk patient population.
• Performs concurrent medical record review using specific indicators and criteria. Monitors the quality, frequency and appropriateness of healthcare delivery by post-acute providers and reports variations of plan of care, health status, or psychosocial issues to PCP and appropriate members of the care team. Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in coordination of care across the healthcare continuum.
• Serves in an expanded healthcare role to collaborate with interprofessional colleagues, and patients/families to ensure care coordination, close monitoring, and readmission prevention for specially defined high and rising risk patient populations promoting quality and efficiency in the delivery of health care across multiple care settings.
• Supports, participates, and coordinates activities for the preparation and completion of audits, chart reviews, quality reporting and regulatory reviews. Collaborates with the clinical leadership and business intelligence teams to track clinical performance and interventions that support clinical and administrative outcomes, as applicable.
• Responsible for interpreting and providing appropriate interventions to automated alerts and notifications in remote patient monitoring.
Competencies and skills:
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.
• ANALYSIS AND DECISION MAKING: Uses decision making processes and tools to analyze situations and make effective decisions.
• TEAM WORK: Contributes to fullest potential to achieve team goals.
• PATIENT AND FAMILY CENTERED CARE: "Provides Patient and Family Centered Care to patients, families, visitors and internal customers"
• CLINICAL POLICIES AND STANDARDS: Applies knowledge of clinical standards, policies, and procedures relevant to function and organization.
• Registered Nurse License
Education equivalent experience:
• Minimum: Associate of Science in Nursing; Bachelor of Science in Nursing (preferred)
Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships. The incumbent must be able to take appropriate action when required.
Required Work Experience: Three (3) years of healthcare experience. Excellent written and oral skills, with the ability to engage, inspire, build credibility and trust with peers and patients. Collaborative working style with the ability to work across different teams, areas of expertise, and adapt to various environments and clientele. Highly organized and self-motivated individual with ability to adapt to various assignments and ability to work autonomously.
Minimum: Associate of Science in Nursing; Bachelor of Science in Nursing (preferred).
• Bending and Stooping 60.00%
• Keyboard Entry 80.00%
• Lifting or Carrying 0 - 25 lbs Non-Patient 60.00%
• Pushing or Pulling 0 - 25 lbs Non-Patient 60.00%
• Pushing or Pulling 26 - 75 lbs Non-Patient 60.00%
• Pushing or Pulling > 75 lbs Non-Patient 60.00%
• Reaching 60.00%
• Repetitive Movement Hand/Arm 80.00%
• Sitting 80.00%
• Standing 80.00%
• Walking 80.00%
• Audible Speech 80.00%
• Hearing Acuity 80.00%
• Depth Perception 80.00%
• Distinguish Color 80.00%
• Seeing - Far 80.00%
• Seeing - Near 80.00%
• Computer Monitor 80.00%
• Wet or Slippery Surfaces 40.00%
Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.