RN - Population Health - FT - Days - MHS

Location:

Miramar, Florida

We have an outstanding reputation for providing patient- and family-centered care that exceeds all expectations. Together, we have created an award-winning, nationally-recognized system where every effort is focused on delivering Deeper Caring and Smarter Healthcare throughout our communities. Career opportunities exist on diverse teams across our many facilities where you can search open positions and apply online to join #teamMHSflorida.

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Summary:

Under the direction of the Population Health Management leadership, the Population Health Registered Nurse (PHRN) serves as a liaison between the Memorial Healthcare System (MHS), Memorial Health Network (MHN), Broward Guardian, ACHN, Memorial Physician Group (MPG), community providers, post-acute care facilities, external healthcare organizations, and the patient. The PHRN follows nursing processes and protocols and implements systems of care that facilitate care coordination and close monitoring of specially defined, high and rising risk patient populations attributed to value-based programs or MHA. The PHRN fosters an inter-professional team-based approach ensuring continuity of care extends beyond the acute care boundaries. The PHRN roles can include a focus on care management, quality, post-acute transitions, remote patient monitoring, care coordination or all of the above.

NOTE: The role involves traveling to several skilled nursing facilities.

Responsibilities:

Supports, participates, and coordinates in preparation and completion of quality audits, quality reporting and regulatory reviews. Collaborates closely with the Population Health Management leadership and Population Health Service Organization Business Intelligence teams to review and provide input on utilization trends. Participates in ongoing process improvement activities through the application of clinical paths, QA processes and other related activities. Ensures that remote patient monitoring processes and customer services are continuously monitored for quality, cost effectiveness, and efficiency.Responsible for longitudinal patient engagement in remote patient monitoring program. Participates in ongoing process improvement activities through the application of clinical paths, QA processes and other related activities. Ensures that processes and services are continuously monitored for quality, cost effectiveness, and efficiency.Conducts initial intake, assessment, identifies and manages health and safety risks including assessment of social determinants of health, functional status, health risk assessment, and medication clarification and education. Discusses assessment with Population Health Nurse II for co-signature on assessment. As appropriate, discusses patients’ eligibility for population health management services or disease management programs. Assesses patient/caregiver capacity and willingness to participate in such programs.Follows the patient-family centered care plan developed by the Population Health Nurse II. Initiates patient conference with Population Health Nurse II for modifications to care plan. Under the guidance of the Population Health Nurse II provides telephonic care/case management services including but not limited to health risk assessment, medication clarification, clinical-decision making, remote patient monitoring, and disease management for rising to high risk patient population. Applies evidence-based clinical guidelines and protocols to promote high quality healthcare delivery.Performs concurrent medical record review using specific indicators and criteria established by the Population Health Nurse II. Monitors the quality, frequency and appropriateness of healthcare delivery by post-acute providers and reports variations of plan of care, health status, or psychosocial issues to PCP and appropriate members of the care team. Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in coordination of care across the healthcare continuum.Chronic condition management including remote patient monitoring referral process, which includes, but is not limited to, eligibility assessment, medical record extraction, provider/physician order entry, patient consent, handoff communications and escalation of abnormal values. Provides telephonic triage and monitoring using established disease-specific protocols. Through utilization of remote patient monitoring technology and other tools, responds to customers’ written, or telephonic communications or inquires with respect to disease management.

Competencies:

ACCOUNTABILITY, ANALYSIS AND DECISION MAKING, CLINICAL POLICIES AND STANDARDS, CUSTOMER SERVICE, DISEASE MANAGEMENT, PATIENT AND FAMILY CENTERED CARE, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR, TEAM WORK

Education