ac72ca79a393-37437-38518059

Carteret Health Care • 28557 • 14h ago

RN Population Health

JOB RELATIONSHIPS
- Responsible to the Supervisor of the ACO Department. Interacts consistently with ACO leadership and medical practice. Provides care coordination to patients within ACO practices.
DEFINITION OF POSITION
- Coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family-centered.
QUALIFICATIONS
- Professional
  - Registered Nurse with current North Carolina license
  - Previous experience in caring for chronic disease patients required.
  - 3-5 years of 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.
  - Ability to identify and implement appropriate patient communication strategies and overcome accessibility, barriers, as required.
- Professional Competencies
  - 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.

PIac72ca79a393-37437-38518059

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