Population Health Nurse | Sturgis Clinic | Full Time - 40 Hours
Monument Health
- Sturgis, SD
- Permanent
- Full-time
- Serve as a liaison between patients, families, and the interdisciplinary healthcare team to ensure that patient needs are met.
- Conduct health risk assessments and screenings, providing education and referrals as needed.
- Develop and implement population health initiatives aimed at improving the health of defined patient populations.
- Monitor and evaluate the effectiveness of population health interventions.
- Collect and analyze data to identify trends and areas for improvement in population health.
- Serve as a resource to other nurses and healthcare professionals on population health topics.
- Advocate for policies and practices that improve population health.
- Collaborate with community partners to develop and implement programs that address social determinants of health.
- Disseminate information on best practices in population health.
- Provide leadership and direction in the development of population health programs.
- Works collaboratively with members of the care team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the clinician.
- Post reminders to secure that all co-morbidities are discussed and documented during AWV.
- Establish competencies related to AWV screenings such as PHQ-9, TUG and Mini-Cog and assists in the training of the care team to perform these screenings.
- Establish counseling services/resources within the practice to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety and advanced care planning.
- Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases; determine frequency for clinician visit and CCM encounters; maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
- In collaboration with the primary care physicians, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
- Participate in huddles with primary care physician and care team; identify scheduling opportunities, special needs for patients, patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments requiring rescheduling.
- Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, AWV scheduling, transition of care follow-up calls/visits, and CCM encounters.
- Collaborate with stakeholders to establish a method for assigning patients into a panel listing by clinician that is routinely utilized for scheduling purposes; utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers.
- Other duties as assigned.
Education - Completion of a nursing education program that is approved by a board of nursingCertification - Registered Nurse (RN) - South Dakota Board of Nursing; Certified Care Manager certification (in place or acquired within 12 months); Health Coaching Certification (in place or acquired within 12 months)Experience - 2+ years caring for chronic disease patientsPreferred:Experience - 2+ years provider practice or clinic health; 2+ years Care Coordination, Case Management, Home Health or Behavior Health; 2+ years health information systemsPhysical Requirements:
Medium work - Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.Job Category NursingJob Family Ambulatory NursingDepartment CS Value Based Incentive ProgramScheduled Weekly Hours 40ShiftEmployee Type Regular15 Corporate Services DivisionMake a difference. Every day.Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.