The Population Health Nurse is respnsible for the implementation of Comprehensive Primary Care’s (CPC) Population Health services program with diverse job functions designed to meet specific contractual and program related requirements. This role focuses on improving the health status and care for individuals with chronic conditions: potentially complex medical, mental health, and psychosocial issues: and implementing the utilization review, clinical review plan approvals, discharge planning, and transitional case management processes for individuals covered by health plans who have delegated the responsiility to Comprehensive Primary Care.
We offer a diverse work experience that empowers colleagues for career success. In addition to skill and experience, we also seek to attract and retain colleagues whose beliefs and behaviors are in alignment with our core values of collaboration, innovation, caring, integrity and accountability.
Care and Condition Manaagement
- Carries out transitional care management program.
- Conducts chronic condition management for individuals with target chronic conditions.
- Conducts outreach through face to face follow-up, by telephone, secure e-mail, or postal mail with goal of engaging enrollee.
- Assesses individual needs and develops plans to address needs/issues related to conditions and/or overhall health
- Actively participates with community-based initiatives related to care management and transitions of care.
- Conducts patient education regarding condition and symptom management, red flag warning signs, the importance of adhering to medications and evidence-based guidelines, and refers to customer-sponsored or community supported programs.
- Establishes self-management goal(s) with patients using self-management support concepts and motivational interviewing techniques
- Using the nursing process, conducts prospective, concurrentm and restrospective review activities for uncomplicated and complex cases for healthcare facilities.
- Coordinates and communicates with health plans as appropriate.
- Carries out transitional case management porgram for uncomplicated and complex cases through avoidance of hospitilization or facilitating the timely discharge of hospitalizaed members including discharge planning.
- Applies the principles of the nursing process to care and condition managemnet of individuals with chronic conditions and those needing transitional care coordination.
- Assists in provider and office staff education regarding Population Health initiatives.
- Identifies oppurtunities for continuous improvement, develops related plans of action, and implements process and documentation improvements.
Education/Experience (Minimum Requirements):
Registered Nurse and Bachelor’s degree in nursing.
Certified Case Management or Chronic Case Nurse preferred.
Specific Knowledge, Skills, Licenses, Certifications, Etc:
Three years clinical nursing experience in acute case setting. Additional experience in ambulatory care, home health, physician practice, utilization management, or other community setting preferred.
Ability to communicate orally and in writing clearly and assertively.
Ability to analyze, plan, think critically and problem-solve effectively.
Ability to organzie, prioritze, and be flexible.
Ability to work within a variety of teams.
Strong attention to detail.
Demonstrate and maintain high level of accuracy.
Proven customer relations skills.
RN with current Maryland license in good standing.
The above statements are intended to describe the general nature and levels of the work preformed and are not exhaustive lists of all duties, responsibilities, knowledge, skills, and abilities and working conditions associated with the job. As changes occur CPC reserves the right to modify the above description.