Population Health Nurse - Accountable Care Organization
About the Job
Employment Type:Full time
Holy Cross Physician Partners is expanding its team and looking for motivated and engaged nurses to join their integrated health system! If you are a RN interested in improving access to and coordination of care for patients and providing high quality care to help improve patient outcomes, then our Population Health Nurse role might be for you. Come be a part of a team that is committed to safe transitions of care after discharge, getting the right patient at the right time to the right intervention, reducing unnecessary costs, promoting preventative wellness, managing chronic conditions, and educating and empowering patients to practice preventative medicine.
Better Care. Smarter Spending. Healthier People.
The Population Health Nurse is part of Holy Cross Physician Partners, a clinically integrated health care provider network that unites independent and employed physicians along with the Holy Cross hospital in a program that drives improvements in efficiency as well as health outcomes. Our approach involves a fundamentally different and more comprehensive approach to coordinating care across the health care continuum to ensure the right care is delivered at the right place at the right time—all at the right cost. We feel this approach is crucial to a sustainable, high quality health care delivery system that provides value to patients, employers and payers by delivering outstanding clinical care and outcomes while reducing inefficiencies and redundancies and their associated costs.
- Care transition coaching and coordination.
- Population management.
- Conduct targeted reviews of medical documentation.
- Perform psycho-social assessment, identify patients in need of behavioral health support and refer as appropriate.
- Work flow process facilitation.
- Health plan clinical liaison; utilize health plan data and portals.
- RN required.
- Valid driver's license and evidence of automobile insurance.
- Associates in Nursing required
- Local and out-of-state travel as needed. Participation in after-work activities as required. Evening and weekend work as necessary.
- Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.
- Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost) for individual users of health care and patient populations.
- Certification as needed or available for Health Coaching or Population Health Management
- Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period
- Knowledge of confidentiality, legal and liability issues
- 5 years of clinical and case management/health coach experience
- Clinic/Physician office, home care, public health and/or social service experience preferred.
- Experience in patient education preferred
- Experience with Allscripts Enterprise, Meditech, IDX and McKesson Medventive PHM preferred
- Certification in case management (CCM), public health and/or community health preferred
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.