The Population Health Nurse plays a highly visible and critical role in providing leadership for the development and deployment of a cogent strategy for building a culture of health for the patients in the Tyler Holmes Rural Health Clinics. The Population Health Nurse will be a wellness advocate providing leadership for wellness programs that drive Tyler Holmes Memorial Hospital’s efforts to improve the overall health of our patients with chronic disease in an effort to successfully manage the increasing cost of health care.

Responsibilities :

• Coordinates all Medicare Wellness face to face visits
• Carries out transitional care management program.
• Conducts chronic condition management for individuals with target chronic conditions.
• Conducts outreach through face to face follow-up, by telephone, secure e-mail, or postal mail with goal of engaging enrollee.
• Assesses individual needs and develops plans to address needs/issues related to condition(s) and/or overall health.
• Conducts patient education regarding condition and symptom management, red flag warning signs, the importance of adhering to medications and evidence-based guidelines, and refers to customer-sponsored or community support programs.
• Using the nursing process, conducts prospective, concurrent, and retrospective review of activities for uncomplicated and complex cases for healthcare facilities.
• Carries out transitional care management program for uncomplicated and complex cases through avoidance of hospitalization or facilitating the timely discharge of hospitalized members including discharge planning.

Minimum Qualifications:

• Registered Nurse degree
• Minimum 1 year clinic professional experience.
• Demonstrated ability to work with multi-departmental teams to successful achievement of patient and organizational goals related to Patient Centered Medical Home.
• Demonstrated ability to lead through the creation of innovative strategies, methods, and approaches, working independently and in a team environment.
• Have a basic understanding of CPT, ICD 10 and Hierarchical Coding Concepts

Working Conditions:
Work is performed within a normal office environment with ambient temperatures and involving occasional reaching, stretching, bending, and moving about