Population Health Nurse
Grand River Medical Group
1 Positions
ID: 27830
Posted On 01/24/2023
Job Overview
Population Health Nurse
Position is for the Multi-Specialty Clinic location
Grand River Medical Group is seeking a self-motivated, detail oriented, responsible nurse (RN) to work in our Population Health Department.
As a Population Nurse you will focus on care coordination, working alongside our primary care doctors and nurses to create a personalized care plan for patients with chronic health conditions. This includes monthly phone calls with patients where you will discuss the plan, work through barriers, and set new goals. You will also assist with coordinating care and resources when patients are leaving the hospital as needed such as medication refill requests, test results, appointment scheduling and ordering DME or referrals.
Our Population Health Department continues to grow and evolve as we begin new payor and ACO relationships. As part of the Population Health Team, you will assist with groundbreaking changes in the way we provide care to patients in the future with a large focus on quality improvement.
The ideal candidate will have a passion for community health and for promoting positive change in the health of patients. You will utilize critical thinking skills and work independently or part of a team. You will be responsible for prioritizing your workload and being able to multi-task while continuing to provide an exceptional patient experience.
This is a full-time position, 30-34 hours per week. This position has a flexible schedule, with the ability to work a hybrid model of some work from home and some in office days, with no evening or weekend requirements. All nursing positions have the ability to pick up shifts at other clinic locations as desired. Grand River Medical Group's clinics are typically open from 7:30 a.m. - 5:00 p.m.
Duties include but are not limited to:
- Establish relationships with patients with various catastrophic/complex/chronic conditions based on established criteria and assist them in coordinating care and resources.
- Collaborate with clinicians to provide care management across the health care continuum for patients.
- Participate in quality initiatives, transition of care, and case management within the scope of licensure.
- Provide a coordinated, strategic approach to early detection and effectively manage the chronically ill patient population.
- Implement an effective internal tracking system for identified patients to assess progress over time.
- Coach patients/families toward successful self-management of their chronic disease.
- Utilize tools and documents that support a guided care process and collaborate with patient/family toward an effective plan of care.
- Assess patient and family's unmet health and social needs and connect patient to appropriate resources when necessary.
- Develop a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate.
- Monitor patient adherence to plan of care and progress toward goals in a timely fashion and facilitate changes as needed.
- Establish process for patients/families to determine and request the level of care coordination support they desire over time.
- Develop care plans that are custom tailored to individual patients.
- Communicate with patients face-to-face in the office setting, by telephone, or by email.
- Develop an individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes.
- Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
- Cultivate and support 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.
- Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
Education/Experience/Skills:
- Must be a graduate from an accredited school of nursing for Registered Nurses.
- Minimum of three years of professional nursing experience in clinical or community health setting required; previous care coordination, case management or home health experience preferred.
- Must be a licensed RN with an active license to practice in the state of Iowa; BSN preferred.
- Health Coaching certification preferred.
- Basic Life Support (BLS) certification required.
We offer: A competitive hourly wage plus a very attractive benefits package including vacation and much more.
Grand River Medical Group is an independent physician owned practice located in Dubuque, IA. We provide a wide range of healthcare services from primary care to subspecialty care for adults and children. We currently employ over 300 team members who help support the practices and clinical operations of over 65 physicians, nurse practitioners and physician assistant clinics, our urgent care network, and four dialysis units located in Iowa (Manchester and Dubuque) and Wisconsin (Platteville and Richland Center).
Grand River Medical Group is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, religion, color, national origin, sex, age, sexual orientation, gender identity or expression, status as a protected veteran, or status as a qualified individual with disability.