Population Health Nurse
2 weeks ago
Apply Now at Vista Health System and begin working and servicing patients in our community Invest your time in providing quality care for the communities we serve
Vista Health System is a community healthcare provider; a network that includes Vista Medical East campus and the Vista Lindenhurst campus that includes Vista Ambulatory Care Center, Lindenhurst Surgery Center, LLC, a freestanding Emergency Center and the Medical Office Building. The Vista Health system also has several locations for imaging, patient therapy and physician offices throughout Lake County, Illinois.
Vista Health System is seeking a Population Health Nurse. This RN will coordinate team-based care to provide health services to individuals, through effective partnerships, their caregivers/families, community resources and their physician.
The RN will facilitate a "shared goal model" within and across settings to achieve coordinated high-quality care that is patient and family centered. Key job responsibilities to include bit not limited to:
- Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
- Coach safe transition of care after discharge
- Coach and educate patients/families toward success self-management of their healthcare
- Assess patient and family's unmet health and social needs and share resources within community
- Develop a care plan based on mutual goals and the patient, family and providers 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 n and facilitate changes as needed while reducing unnecessary costs
- Cultivate and support primary care and sub-specialty co-management and timely communication, inquiry, follow-up and integration of information into the care plan regarding transitions in care and referrals
- Ensure effective tracking of test results, medication management and adherence to follow-up appointments
- Implementation and effective internal tracking system for identified patients.
Qualifications:
- RN License in State of IL
- Current BLS
- 3-5 years of clinical or community health settings, preferred Previous Care Coordination, Case Management or Home Health experience preferred.
- Previous experience in caring for chronic disease patients
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