- Manage population health initiatives to support the practices' success in providing value-based care.
- Ability to use insights from clinical, quality, and financial data to inform population health initiatives and care management activities.
- Identify and recruit appropriate patients for care management in collaboration with the medical staff.
- Ability to execute core care management duties:
- Conduct outreach to patients and perform indicated assessments.
- Develop patient-centered care plans in collaboration with medical staff members, with particular focus on chronic disease management, social determinants of health, transitions of care and advanced care planning.
- Implementation of care plans.
- Meet the patient where they are; support the patient without intervention or judgment, use reflective empathetic language and open-ended questions to understand what the patient wants or needs.
- Knowledge of common chronic medical conditions presented in the population served and can:
- Educate the patient on their medical conditions and medications to build and empower self-management skills.
- Use motivational interviewing to promote behavioral change.
- Demonstrate commitment to providing outstanding customer service in a manner that is reflective of our mission, values, and customer service standards.
- Participates in department operations, including team meetings, curbsides with care team members, and functions as member of the clinical care delivery team.
- Complies with established metrics for performance and adheres to documentation and workflow standards.
- Maintains HIPAA standards and confidentiality of protected health information.
- Adheres to departmental/organizational policies and procedures.
- Performs assigned tasks and projects in an efficient and timely manner including any other related duties assigned at manager's discretion.
- Bachelor's degree in nursing required.
- Must possess a current, unencumbered Maine nursing license.
- 3+ years of direct patient care experience is required.
- 1+ years of care management/population health management experience is strongly preferred.
- Prior experience screening for social determinants of health and making connections to community resources is strongly preferred.
- Strong background in ambulatory care prevention, health promotion, condition management, case management and discharge planning preferred.
- A self-starter individual who thrives in a fast-paced, team-based environment that understands how to remove roadblocks and obstacles to achieve desired outcomes.
- Previous experience and comfort utilizing electronic medical record software to review patient records and document care management activities is required.
- Excellent communication skills with a customer-oriented approach.
- Knowledge of medical record documentation requirements and federal/state laws related to the release of health care information.
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population health nurse - Portland, ME , USA, United States - InterMed
Description
Working under the general direction of physicians and advanced practice providers, the role focuses on improving the health and wellbeing of the organization's covered lives by conducting needs assessments and responding to barriers in patients' health and wellness. The Care Management Nurse will be instrumental in assisting risk stratified patients with addressing their health goals and is responsible for providing interventions designed to ensure the coordination and continuity of care and services for at risk patients with complex chronic medical, social, behavioral, or mental health needs over time.Excellent interpersonal skills, engagement skills, and the ability to work independently and collaboratively are key requirements of the job. Critical elements of this position include developing trusting relationships with patients by providing support and advocacy to help achieve health goals, coordinating care to address unmet needs, and effectively communicating to patients, families, and other members of the healthcare team.
ESSENTIAL FUNCTIONS
Monday through Friday 40 hours per week.
InterMed is an equal opportunity workplace and prohibits discrimination or harassment of any kind. We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, gender identity and/or expression, sexual orientation, marital status, disability, veteran status, or any other basis protected by applicable federal, state or local law.
