Population Health Nurse

3 days ago

Oxon Hill, Maryland, United States Greater Baden Medical Services, Inc. Full time
Job Summary

The Population Health Nurse assumes responsibility and accountability for the management of resources through interdisciplinary collaboration to achieve optimal patient outcomes and reduction of readmissions.

This role functions as a clinical resource to ensure that medical services are delivered in a safe and efficient manner, addressing patient needs as expeditiously as possible.

The Population Health Nurse is responsible for providing patient-centered nursing care within a primary care setting.

Key Responsibilities
  • Convey the purposes and services of population health program initiatives offered by GBMS to MCOs and patients
  • Provide patient education on disease process, medications, and self-care management; supply patient with educational materials to re-enforce self-care monitoring
  • Monitor avoidable ER visits for each MCO and reach out to patients to determine reason for ER visit. Provide patient education on best way to utilize medical services.
  • Care manages patients with high ER and Hospital utilization rates
  • Serves as a clinical team leader and resource and provides input of day-to-day clinical activities working closely with the center manager.
  • Provides direct nursing care to patients, including performing assessments, nursing procedures (including injections), and assistance with procedures.
  • Coordinate referrals to specialists and support services as needed
  • Assist the Population Health Manager in identifying and mitigating gaps in care
  • Educate nonadherent patients on the importance of closing care gaps and monitor patients for compliance
  • Assist coordination of post discharge follow up appointments and needed medication and supplies.
  • Coach patients and family in follow-up to chronic health conditions and self-management strategies presented during hospitalization and planned clinic/health care provider visits.
  • Build and maintain positive working relationships with the patients, family members, providers, case managers and other health agency representatives
  • Continuously expand knowledge and understanding of community resources, services, and programs
  • Provide triage services as needed
  • Links patients with case managers of MCOs to assist patients with any case management needs
  • Attends meetings with MCOs to assess GBMS performance and provide support to improve quality metrics
  • Attends community events to promote GBMS efforts in health and wellness
  • Assists with patient education classes related to Diabetes Prevention, Diabetes Self- Management, and Obesity
  • Performs additional duties as assigned
Requirements
  • Education BSN required; ADN with relevant experience will be considered
  • Experience 3-4 years Nursing experience in dealing with chronic disease management and population health; Pediatric experience a plus
  • Licenses and Certifications RN license in Maryland in good standing required BLS certification required
  • Managerial Responsibilities None
  • Supervisory Responsibility None
  • Core Competencies Needed Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully, develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics.
  • Communication Skills - Listen and verbally to solve problems and provide information and direction, ensuring the experience is a positive one.
  • Record issues and resolutions to maintain accurate records and data for further analysis by management.
  • Analytical Skills - The ability to tackle a problem by using a logical, systematic, sequential approach. Possess creative thinking, learning, systems thinking and problem solving. Must be effective at defining and solving problems to ensure that the real, underlying challenge is understood and that solutions actually address it.
  • Healthcare Systems - Knowledge of healthcare and medical terminology.
  • Risk Management/Compliance - Confidentiality principles and laws, maintain compliance with government contractual mandates.
Core Values
  • Quality, Respect, Integrity, Equity, Teamwork, Professionalism, Commitment, Passion
Physical and Mental Demands
  • Ability to cope with stress.
  • The person in this position needs to occasionally move about inside the center
  • Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer.
  • The person in this position frequently communicates with patients and/or employees. Must be able to summarize and exchange accurate information.
  • Must be able to lift or assist moving a patient weighing more than 50 pounds in the event of emergency.
  • Performs with frequent interruption or distractions.
  • Adjust priorities quickly as circumstances dictate.
  • Cognitive ability to analyze, count, summarize and synthesize information from multiple sources.
Work Environment

This job operates in an outpatient office environment.

This role is frequently exposed to fumes or airborne particles, and high stress situations or events.

Position is required to function in a fast paced environment with occasional high pressure or emergent and stressful situations.

Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public.

Function is subject to inside environmental conditions, with occasional outdoor exposures.

Possible exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a clinic and or hospital and medical office environment.

May wear Personal Protective Equipment (PPE) such as gloves or a mask if exposed to hospital environment outside of office.

Compliance

This position requires compliance with Greater Baden Medical Services (Health Center's) compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures.

Such compliance will be an element considered as part of the Population Health Nurse's regular performance evaluation.

Language Skills

Ability to read and interpret written or verbal documents and instructions. Ability to speak effectively to patients, employees and/or stakeholders of the organization. Bilingual a plus.

Travel

Must be able to drive between Greater Baden Medical Services, Inc. locations as required.

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