- Responsible for increasing patient knowledge and self-management of chronic conditions to reduce symptom relapse and hospital re-admission rates.
- Administers screenings and assessments, triaging incoming phone calls, HEDIS measures, and developing care plans, reinforcing medication adherence, and coordinating medical treatment across primary care, behavioral health, psychiatric, and other specialist appointments.
- Serves as empathetic and compassionate patient/family advocate, giving priority to customer service issues and promoting positive interpersonal relationships among patients, providers, and community.
- Provides patient support in relation to health goals via phone, video conference, and/or in person, working to overcome healthcare barriers, giving and receiving feedback on effectiveness through participation in weekly supervision and staff meetings.
- Maintains a collaborative approach, focused on the attainment of organizational goals and objectives while contributing to the development of medical tool kits and educational materials based upon evidence-based practices
- Provides psychoeducation and use motivational interviewing to provide assessment of whole-person-health regarding chronic disease, performing screenings, regular monitoring, prescription assistance, development of adherent and sustainable patient health goals, transition planning, coordination of community resources, and continuous reporting to the patient care team.
- RN with active and current licensure (ADN or BSN preferred)
- Health coaching experience or certification preferred
- Minimum 2 years' experience in case management or care coordination
- Ability to obtain and maintain an Arizona Fingerprint Clearance Card
- HEDIS experience preferred
- Excellent verbal and written communication skills with good time management and problem-solving/critical thinking skills and the ability to work within an interdisciplinary team
- Strong analytical/conceptual thinking skills with the flexibility to manage multiple priorities and able to shift resources and priorities as required
- Up to date with modern office equipment & applications (including EMR/EHR software)
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Population Health - Phoenix, AZ, United States - Denova Collaborative Health
Description
Population Health - RNJob Purpose:
The Population Health RN serves as a patient advocate, building meaningful relationships with patients, engaging them in individual health care plans, and working to improve their health literacy to drive better healthcare outcomes.
Main Duties and Responsibilities:
Triage experience preferred:
critical thinking, ability to perform telephonic triage assessments, interpretation of out-of-range lab values and assessments, and ability to direct patients on appropriate level of care (PCP, UC, 911, Crisis Calls, etc.)
We provide a "whole person" approach to health and promote collaboration among our team of primary care providers and specialists.
Our unique service integration of primary care, behavioral health, addiction medicine, and wellness enables our team to provide better health outcomes.
