Registered Nurse, RN - Population Health Nurse Specialist

Job Profile Summary

​This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards.  In addition, this role focuses on performing the following Performance Improvement/Quality duties: Identifies and executes performance improvement and quality opportunities across the enterprise, enabling successful transformations and driving cost savings, process and product quality, and achievement of business goals. Responsibilities also include partnering with business leaders to provide expert insight on existing processes and procedures, applies process improvement methodologies to achieve PI/Quality objectives, and builds process improvement capabilities.  A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.  The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.   An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience.  Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices.

Job Overview

This role is essential in developing and maintaining an infrastructure for the systematic review and management of complex patients. The position will work closely with PHO medical directors, and leadership, TMIN case managers, TMIN Practice Optimization Coaches (POMs) and primary care providers to review patient records, analyze data, and identify practice and patient outlier utilization, and gaps in quality measures for weekly practice and medical director huddles. Additionally, this position will be responsible for overseeing and reviewing PHO referral management. Currently, the PHO reviews every referral request out of the Hallmark Health PHO. The position would serve as a liaison to PCP practices and patients requesting an out-of-area referral.

Job Description

Minimum Qualifications:

1. Massachusetts RN Licensure.

2. Five (5) years of experience in acute hospital care, ambulatory care or practice-based care, high-risk patient coordination and/or referral management.

3. Current Basic Life Support (BLS) Certification.

4. Experience in population health, quality improvement, or healthcare analytics.

5. Familiarity with value-based care models and risk stratification methodologies.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned.

1.Collaborates with PHO clinical leadership and conduct root cause analysis to identify rising and high-risk, complex patient populations.

2.In collaboration with PHO data analytics team, analyzes and manages patient data to generate reports and lists of complex patients for review, as well as identify outlier practices in certain utilization metrics.

3.Leads and coordinates weekly medical director huddles, ensuring effective case discussions and follow-up planning.

4.Develops and implements a structured framework for the consistent review of patients who have multiple visits to the ED and admissions for ambulatory sensitive conditions, including action planning and outcome tracking.

5.Works with providers and TMIN care teams to ensure alignment with best practices to support value-based care.

6.Serves as a clinical resource to the PHO, specifically engaging with primary care practices and serving as a liaison to the TMIN POMS providing insights and recommendations for supporting successful patient management to reduce cost and improve quality outcomes.

7.Monitors practice progress and ensure timely follow-up on interventions and action items.

8. Identifies trends and opportunities for quality improvement based on data analysis and patient outcomes and support PHO goals for high quality scores.

9.Ensures compliance with regulatory requirements and best practices in care coordination.

10.Acts as a mentor and subject matter expert, supporting providers, and practice staff in integrating patient management strategies into their workflows.

11.Participates actively in PHO Pod meetings and Specialty Pod meetings

12.Contributes to the development of performance incentive plans for PHO Providers.

Hours:  40 hours/week
This position is remote with the exception of occasional onsite meetings in Burlington, MA
 

What We Offer: 

• Compet