About The Role

Job Summary

The Population Health Nurse will work in collaboration with primary care providers and healthcare teams. Primary responsibilities will include the following:

Identification of Medicare patients appropriate for Annual Wellness Visits & execute guided processes to complete the visit.
Effectively coordinate & manage high-risk chronically ill patients through Chronic Care Management & Remote Patient Monitoring utilizing health coaching techniques to assist patients with self-management of their chronic diseases & lifestyle changes to mitigate health risk.
Initiate Transitional Care Management coordinating efforts with post-acute providers (Home Health, PCP, Pharmacy, SNF etc.).

Essential Job Duties

Attend and actively participate in all ACO population health related trainings and meetings including advanced health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on-one meetings, as needed
Works collaboratively with the ACO team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the provider; post reminders to secure that all co-morbidities are discussed and documented during AWV
Attend and actively participate in all Value Based Contract meetings, trainings & patient outreach
Stratify patient population according to risk score. Effectively and efficiently manage patients with multiple chronic diseases; Identify patients appropriate for Chronic Care Management (CCM). In collaboration with the PCP, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
Ensure sharing of positive patient stories or compliments involving care team efforts
Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/visits, CCM encounters, navigate care for patients enrolled in RPM
CMA oversight as directed by Quality & Care Coordination Manager

Secondary Job Duties That May be Reassigned

Perform other related duties as directed by Quality & Care Coordination Manager & Executive Director, Good Samaritan Physician Network

Job Specifications

Current licensure as a Registered Nurse
Minimum of five years of clinical experience required, with at least two years in a physician/group practice or other ambulatory or outpatient setting
Previous Care Coordination, Case Management, Home Health or Behavior Health experience preferred