RN - Population Health & Wellness Nurse

Posted: 03/07/2021

POSITION SUMMARY The Population Health # Wellness Nurse is responsible for taking a transformative approach to care that brings together the patient, healthcare providers, and community resources in the planning, implementation, and evaluation of comprehensive healthcare. They help#patients define and reach their health care goals resulting in improved health and the prevention of disease exacerbation. The Population Health # Wellness Nurse actively participates in program development, data collection, and process improvement of the Chronic Care Management Program and Medicare Wellness Program.#They are responsible for the coordination all aspects of the patient#s care, taking a holistic approach and collaborating with the entire health care team for best results. This role is responsible for assessing and managing needs and symptoms, providing patient information, providing support to the patients and their families and ensuring continuity of care for identified patients. They will meet with patients and families in the clinic and hospital. POSITION QUALIFICATIONS Education and Experience: Bachelor of science/art in nursing field required. Three years clinical experience in the acute care and/or clinical setting preferred. Previous case management experience preferred. Experience with inpatient and outpatient providers. License/Certificates: RN license to practice in the State of Minnesota. Special Skills and Aptitudes: Knowledge of nursing principles, practices and techniques gained through a variety of nursing experience. Exemplifies self-direction with good organizational, analytical and interpersonal skills. Knowledge and compliance of state and federal accrediting agencies. Must possess strong interpersonal, verbal and non-verbal communication and problem-solving skills. Ability to handle confidential information discreetly and appropriately. Ability to develop and implement plans for program/department operations. Ability to adapt resources to meet the needs of the situation. Understanding of the health care system and continuum, including sites of care, delivery models, and the roles of various providers. Proficient computer and telephone skills. Possible after-hours availability to assist relevant patients. ESSENTIAL RESPONSIBILITIES Program Development Demonstrate a commitment to the ongoing development of work flows that support chronic care management, annual wellness visits, and ACO requirements. Participate in the development and maintenance of procedures and workflows to capture best practice standards and promote efficiency, including program criteria, documentation, handoffs and billing. Schedule and oversee interdisciplinary team meetings. Quality Improvement Promote a culture of continuous improvement through quality monitoring, regulatory compliance, and performance improvement activities. Develop and participate in the measurement and evaluation of care processes to identify variations and opportunities for improvement. Lead program specific process improvement projects. Patient Assessments and Care Coordination Identify high-risk patients based on protocol guidelines. Meet with chronic care management patients to assess needs, develop a plan of care, and coordinate appointments and services. Involve patients in decisions regarding their individual preferences and review medical options in an easy to understand vocabulary. Serve as a liaison between physicians and departments to ensure timely quality care is delivered and guide care delivery by all care providers. Act as a clinical resource for patients/families, interdisciplinary teams, and direct care providers. Develop and maintain patient care plans. Community Outreach Build and maintain relationships with community programs and resources. Refer to appropriate internal and/or community resources as needed. Education Prepare and provide education for staff on subjects related to the chronic care management program and wellness program. Plan for and provide patient, family, caregiver education by identifying needs and communicating information clearly. Document education process and response. Participate in in-service programs, education programs, and orientation of new personnel when requested. Regulatory Compliance Maintain an understanding of state and federal regulations and accreditation standards and adhere to them. Maintain compliance with Joint Commission, state and federal rules and regulations through provision of client care, policies, procedures, and documentation. Collaboration Provide consultation to the interdisciplinary team and other healthcare providers regarding complex or high risk cases and psychosocial issues hat affect the care planning process. Monitor patient progress toward goal achievement and patient outcomes. Facilitate appropriate exchange of information between team members and/or community agencies. Provide leadership and promote teamwork. Demonstrate Standards of Excellence when other duties are assigned.
* POSITION SUMMARY
* The Population Health & Wellness Nurse is responsible for taking a transformative approach to care that brings together the patient, healthcare providers, and community resources in the planning, implementation, and evaluation of comprehensive healthcare. They help patients define and reach their health care goals resulting in improved health and the prevention of disease exacerbation.
The Population Health & Wellness Nurse actively participates in program development, data collection, and process improvement of the Chronic Care Management Program and Medicare Wellness Program. They are responsible for the coordination all aspects of the patient's care, taking a holistic approach and collaborating with the entire health care team for best results.
This role is responsible for assessing and managing needs and symptoms, providing patient information, providing support to the patients and their families and ensuring continuity of care for identified patients. They will meet with patients and families in the clinic and hospital.
* POSITION QUALIFICATIONS
* Education and Experience:
* Bachelor of science/art in nursing field required. Three years clinical experience in the acute care and/or clinical setting preferred. Previous case management experience preferred. Experience with inpatient and outpatient providers.
* License/Certificates:
* RN license to practice in the State of Minnesota.
* Special Skills and Aptitudes:
* Knowledge of nursing principles, practices and techniques gained through a variety of nursing experience.
* Exemplifies self-direction with good organizational, analytical and interpersonal skills.
* Knowledge and compliance of state and federal accrediting agencies.
* Must possess strong interpersonal, verbal and non-verbal communication and problem-solving skills.
* Ability to handle confidential information discreetly and appropriately.
* Ability to develop and implement plans for program/department operations.
* Ability to adapt resources to meet the needs of the situation.
* Understanding of the health care system and continuum, including sites of care, delivery models, and the roles of various providers.
* Proficient computer and telephone skills.
* Possible after-hours availability to assist relevant patients.
* ESSENTIAL RESPONSIBILITIES
* Program Development
* Demonstrate a commitment to the ongoing development of work flows that support chronic care management, annual wellness visits, and ACO requirements.
* Participate in the development and maintenance of procedures and workflows to capture best practice standards and promote efficiency, including program criteria, documentation, handoffs and billing.
* Schedule and oversee interdisciplinary team meetings.
* Quality Improvement
* Promote a culture of continuous improvement through quality monitoring, regulatory compliance, and performance improvement activities.
* Develop and participate in the measurement and evaluation of care processes to identify variations and opportunities for improvement.
* Lead program specific process improvement projects.
* Patient Assessments and Care Coordination
* Identify high-risk patients based on protocol guidelines.
* Meet with chronic care management patients to assess needs, develop a plan of care, and coordinate appointments and services.
* Involve patients in decisions regarding their individual preferences and review medical options in an easy to understand vocabulary.
* Serve as a liaison between physicians and departments to ensure timely quality care is delivered and guide care delivery by all care providers.
* Act as a clinical resource for patients/families, interdisciplinary teams, and direct care providers.
* Develop and maintain patient care plans.
* Community Outreach
* Build and maintain relationships with community programs and resources.
* Refer to appropriate internal and/or community resources as needed.
* Education
* Prepare and provide education for staff on subjects related to the chronic care management program and wellness program.
* Plan for and provide patient, family, caregiver education by identifying needs and communicating information clearly.
* Document education process and response.
* Participate in in-service programs, education programs, and orientation of new personnel when requested.
* Regulatory Compliance
* Maintain an understanding of state and federal regulations and accreditation standards and adhere to them.
* Maintain compliance with Joint Commission, state and federal rules and regulations through provision of client care, policies, procedures, and documentation.
* Collaboration
* Provide consultation to the interdisciplinary team and other healthcare providers regarding complex or high risk cases and psychosocial issues hat affect the care planning process.
* Monitor patient progress toward goal achievement and patient outcomes.
* Facilitate appropriate exchange of information between team members and/or community agencies.
* Provide leadership and promote teamwork.
* Demonstrate Standards of Excellence when other duties are assigned.