Population Health Nurse

Job Summary: Coordinates team-based care to provide health services to individuals through effective partnerships with patients, caregivers/families, community resources, and physicians. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality patient and family centered care. Provides professional nursing care for the comfort and well-being of patients under the direction and supervision of a licensed physician, physician assistant or nurse practitioner. Collaborates with own team and other disciplines in the provision of care. Completes documentation of patient care, patient condition, reactions and response to treatment in a timely manner and tracks patient progress. Maintains focus on patient centered care and customer service.

Essential Functions:

• Consistently uses an outward mindset and puts forth exemplary effort in accomplishing his/her goals and objectives in a manner that helps others to achieve their goals and objectives.
• Collaborate with patients/family toward an effective plan of care including but not limited to assess patient and family’s unmet health and social needs, provide effective communication to improve health literacy, develop a care plan based on mutual goals with patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient’s adherence to plan of care and progress towards goals in a timely fashion, facilitate changes, as needed and create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
• Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes, Educator, Dietician)
• Cultivates and supports 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.
• Serves as a point of contact, advocate, and informational resource for patient, family, care team, payers, and community resources.
• Facilitates/attends meetings as needed between patient, families, care tem and community resources.
• Attends and actively participates in Care Coordinator related training and meeting activities.
• Performs regular visits to provider, patient and family support and education.
• Collects data and writes brief reports to meet evaluation needs of the program.

Minimum Qualifications: Current licensure in Michigan as an RN or LPN.

Knowledge, Skills & Abilities: Experience in a physician health care office or similar setting, preferred. Clear oral expression: oral comprehension includes listening to and understanding others; speaking clearly such that others understand; deductive and inductive reasoning skills; ability to write clearly; use of technology such as EMR, Athena preferred. Ability to work with diverse patient and staff populations with sensitivity to cultural and spiritual influences impacting patient care. Efficiently manage time with minimal supervision.

Working Conditions: Work in an unpredictable environment encountering stressful situations and exposure to body fluids and infectious diseases.

Physical Requirements: Constantly see/visual acuity, handle/grasp/feel, talk/hear, taste/smell. Frequently sit. Occasionally lift/carry 1 to 25 lbs.