The Population Health Nurse/Project Manager has the responsibility to provide care coordination across the continuum of care through telephonic population and disease management. The Population Health Nurse/Project Manager will identify, plan, coordinate, implement, monitor and evaluate appropriate cost-effective health care and utilization of services for patients of the Mid-Valley Healthcare system in order to optimize patient function and well-being. This will include areas of behavioral health, chronic care, transitional care and managing the workflow. Additional projects may be managed in ACO, ACH, and P-TCPi. Managing future project implementation such as WRHAP, PCMH and JCAHO. This position provides for optimal outcomes through collaboration with the client, the family, the physician, health plan and other members of the healthcare team.
POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA
Current licensure as a Registered Nurse required.
Previous experience in caring for chronic disease patients preferred such as diabetes, COPD, CVA, CHF, etc.
3-5 year experience in clinical or community health settings preferred.
Previous Care Coordination, Case Management or Home Health experience preferred
Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills.
Proficient in communication technologies (email, cell phone, etc.).
Effective organizational skills and demonstrates ability to maintain accurate notes and records.
Previous experience with health IT systems and data reports preferred.
Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
Ability to speak a relevant second language preferred.
Knowledge of the influence of cultural and spiritual values on health care.
General knowledge of available health care and community resources appropriate for populations served.
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.
Core values consistent with a patient/family-centered approach to care.
Demonstrates professional and effective written and verbal communication skills.
Demonstrates a positive, respectful attitude and professional customer service.
Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns
Recognizes and responds to opportunities for improvement.
Demonstrates continual learning skills, effects changes in approach to care based on established, evidence-based practice.
Demonstrates professional practice behavior.
Provides mentoring/coaching of other population health and care coordination team members.
Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).
Demonstrates understanding in use of IT resources and patient databases.
Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources
1.Greets all patients, visitors, physicians, and other staff members in a courteous, respectful and professional manner at all time. Responds to all patients with empathy and positive interpersonal skills at all times.
2.Reports for scheduled shift on time and prepared to assume responsibilities.
- Reports to work in proper uniform/attire.
- Leaves for meal break on time and returns on time.
- Varies work schedule to meet the needs of the department.
- Ensures the department manager has approved all scheduled overtime.
- Seek supervisor approval before working beyond scheduled hours that will result in overtime.
- Schedules all time off with supervisor's approval.
- Strictly adheres to hospital attendance/tardiness policies 100% of the time.
- Performs all duties as assigned.
- Wears I.D. badge in a visible location at all times on hospital property.
- Protects I.D. and access badge and reports any issues or loss immediately to supervisor or to the Human Resource Department.
3.Attends and participates in meetings and is responsible for information communicated at meetings and in email.
- Attends all mandatory in service on a timely basis as scheduled.
- Participates as an active team member at staff meetings.
- Reads communications and acts upon in a positive and informative manner.
4.Identifies own educational needs and maintains appropriate skill level through educational opportunities.
5.Exercise a commitment to practicing behaviors that are in agreement with the spirit of cooperation and reflect the values described in the Code of Mutual Respect and Professionalism.
6.Assists all patients, family members, physicians, visitors, and employees in a professional and courteous manner.
Extends special attention and sensitivity to all patients, visitors, physicians, and fellow employees.
- Actively promote diversity and inclusion across organization for both patients and coworkers while avoiding any language or actions considered to be discriminatory or derogatory regarding race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability, veteran status, military obligations, and marital status.
- Assists in maintaining an atmosphere of cooperation and teamwork with other departments and community partners.
- Demonstrates a genuine willingness to prevent or resolve inter-personal conflicts.
- Demonstrates the ability to participate in and/or implement team decisions.
- Adheres to HIPAA and all applicable privacy laws at all times, only sharing information on a need to know basis.
7.Follows Infection Control procedures at all times.
- Clinical Personnel: Strictly adheres to standard precautions by adhering to the usage of personal protective equipment when handling blood or body fluids.
- Non-Clinical Personnel: Washes hands and other skin surfaces with soap and water thoroughly and often in an effort to control spreading of germs within the department and facility.
- Adheres to isolation procedures at all times as applicable.
8.Adheres to the following environmental care standards.
- Demonstrates adequate knowledge of safety policies and procedures, the use of MSDS sheets, hazardous material procedures, and safety codes.
- Code Blue, Code Gray, Code Silver, Code Amber, Code Red, Code Orange, Rapid Response Team
- Demonstrates adequate knowledge of security issues, i.e. personal protection, protection of personal and hospital property.
9.Be familiar with and comply with the Mid-Valley Hospital & Clinic Personnel Handbook and Policies.
10.Be familiar with the collective bargaining agreement (Union Contract) of the UFCW 21 and Mid-Valley Hospital.
11.Demonstrates the ability to adapt to varied age-specific patient populations.
Current state nursing license.
BS in Nursing from an accredited college/university.
Ability to communicate clearly and effectively: delegate and coordinate through leadership skills.
Ability to communicate with people of diverse backgrounds and educational levels; i.e. patients, families, employees, physicians, etc.