Description
Summary of Position:
Barton Health's Population Health and Improvement team delivers innovative patient-centered initiatives and services impacting the overall health and wellness of individuals and the entire populations to which they belong. The Population Health RN delivers consistently exceptional population health services to the community, patients, customers, employers, and providers. The Population Health RN works collaboratively with all members of the patient's care team, including patients and their families, to manage and improve health outcomes, reduce costs, and enhance the experience of care. This position will partner with physician leadership and various management teams in the development, implementation, and delivery of clinical quality initiatives and related activities to support population health. The RN also serves as a liaison with customers, employers, physicians, and community agencies.
Qualifications
Education:
● Completion of an accredited Nursing program.
● Bachelor's degree preferred in Nursing (BSN), Business, Healthcare Administration or related field.
Experience:
● Five years of experience in hospital setting, primary care, or health plan, setting.
● Care Coordination, Disease Management or Population Health experience preferred.
● Patient Centered Medical Home (PCMH) accreditation experience preferred.
Knowledge/Skills/Abilities:
● Expert knowledge of Word, Excel, PowerPoint, Google Suite and supporting computer programs.
● Excellent interpersonal and communication skills.
● Presentation skills necessary for population health and quality subject matter.
Certifications/Licensure:
● RN license in the state of California required.
● RN license in the state of Nevada preferred.
● Health Coach Certification preferred.
● Patient Centered Medical Home Content Expert Certification (CEC) preferred.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
● While performing the duties of this job, the employee is frequently required to walk, stand, sit, and talk or hear.
● The employee is occasionally required to use hands to finger, handle, feel or operate objects, tools, or controls; and reach with hands and arms.
● The employee is occasionally required to climb or balance; stoop, kneel, crouch, or crawl.
● Specific vision abilities required by this job include close vision, color vision, and the ability to adjust focus.
● The employee must occasionally lift and/or move up to 25 pounds.
Working Conditions
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
● Routine Hospital/Healthcare & Office/Administrative conditions.
● Contact with patients and guests under a wide variety of circumstances.
● Subject to varying and unpredictable situations, including the handling of emergency or crisis situations.
● Subject to pressure due to irregular hours, frequent interruptions and stressful situations due to multiple demands.
● Occasional travel to various health system locations.
Essential Functions
1. Provides consistently exceptional care at all times.
2. Provides a coordinated , strategic approach to detect early and manage effectively the chronically ill patient population
3. Coordinates care between providers and other organizations to ensure that patient needs and preferences are met over time for health services and information.
4. Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
5. Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care.
6. Assesses patient and family's unmet health and social needs
7. Provides effective communications to improve health literacy.
8. Develops a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate. Monitors patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
9. Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
10. Coaches patients/families toward successful self-management of their chronic disease.
11. Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator).
12. Ensures effective tracking of test results, medication management, and adherence to follow-up appointments.
13. Creates ongoing processes for patients/families/caregivers to determine and request the level of care coordination support they desire over time.
14. Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
15. Coordinates the implementation of population health management tools in the practice (such as screening, self-management, and other tools and resources).
16. Uses evidence-based guidelines and best practice care standards to direct care management and coordination of care.
17. Uses disease management registries and other population health reports or tools.
18. Reviews and analyzes population data for Barton Health such as gaps in care and metrics to inform improved health outcomes for these patients.
19. Fosters innovation and problem solving with population health services staff and ensures collaboration and coordination between population health services staff, related project teams, and other functional areas of Barton Health.
20. Collects data, conducts data analysis, and prepares reports for programs within areas of responsibility including condition management, and care coordination.
21. Understands definitions of quality measures including applicable codes from data sources, attribution and compliance.
22. Participates in and completes patient safety initiatives appropriate to the position, and conducts all job responsibilities according to the mission and values of Barton Health.
23. Responds to the needs of the department by performing other duties, as necessary.
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