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Population Health RN

Apply Job ID 19484 Date posted Jun. 03, 2021 Location Full Time / Part Time Full time (FT)

Quad/Graphics

Nearly thirty years ago, QuadMed was born out of the idea that health care should be simple. By providing employers and their employees with quality onsite and near-site primary care, with a focus on wellness and prevention, we make a culture of health and well-being possible. Our caregivers working as a team, and with ample appointment times, have the opportunity to build meaningful patient relationships that produce measurable health improvement results. We’re proud to be a nationally recognized leader committed to transforming health care for the better. At QuadMed you can showcase your skills and your passion for patient care.

We are excited to offer an exceptional opportunity as a Population Health RN with the Huntington Ingalls Industries Family Health Center, Operated by QuadMed located in Pascagoula, MS. This is a remote position with up to 10% travel to our Pascagoula clinic.

Reporting to the local Clinical Leadership, the Population Health Nurse will have a shared responsibility between Client, Clinic and QuadMed Corporate.  This includes the development and monitoring of health improvement activities for positively impacting and improving patient outcomes in the continuum of care.
The Population Health Nurse will focus on supporting both the clinical care team and population health services team in improving health outcomes across the population we serve.  This position will work closely with the QuadMed health and wellness center providers, medical assistants, and other QuadMed wellness services providers (i.e. CDE, RDN) on a daily basis.  S/he will utilize population health management tools, clinical disease guidelines for outreach, identification of care gap analysis in creating work plans for the population health nurse and team to address population health outcomes.  This role is responsible for working closely with the Clinic Staff, Clinical Quality, and Operations to enhance clinical quality outcomes on an individual patient level, assist patients throughout the continuum of care and at a population level.  This role will have direct accountabilities and collaborative responsibilities to achieved improvement in defined population health metrics.  The interactions of this role will encompass both patient and staff contacts. 

KEY RESPONSIBILITIES
Analytic

  • Assesses client’s overall population for health improvement opportunities to analyze data for trends in health outcomes, gaps in clinical care, and high risk high cost patient conditions (such as hospitalization, ER/UC, prescription medication trends)
  • Researches best practices and methods along with clinical practice guidelines to improve processes that enhance clinic metrics and health outcomes
  • Effective use of population health management tool to perform gap analysis on population (i.e.  chronic disease, prevention, social factors)
  • Collaborates with clinical quality to generate meaningful and accurate population health reports, assuring linkage to corporate and client objectives, and performance guarantees
  • Identifies and interprets data sets from sources such as raw claims files/EMR disease registry/clinic data warehouse
  • Collaborates with corporate leadership to define the requirements and validate population health data reported at the provider, clinic, programming, and client level

Work plan development and accountability

  • Creates a strategic outreach program that is customized to their workforce, goals and budget; utilizes data (such as health assessment data, claim/utilization data, employee survey data, and biometric screening results) to provide outreach services
  • Coordinates and performs regular, proactive outreach to patients according to their work plan
  • Assists in the development of Quality Improvement studies

Collaboration with patients , providers and health care team

  • Collaborates with health and wellness center providers to identify high risk/target populations (i.e. high risk diabetics, noncompliant patients)
  • Collaborates with certified diabetes educator, RDN, Wellness coordinator for targeted outreach
  • Provides case management services by being a patient advocate, resource and contact person for patients and families assisting the clinical team’s RN in these endeavors
  • Works as a community partner to improve linkages to outside resources
  • Assesses, plans, directs and evaluates total nursing care as determined by the patient’s age-related physical, psychosocial, and cultural needs in accordance with established standards, policies and procedures of QuadMed and assigned client groups

Other duties

  • Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations
  • Completes all documentation accurately, timely and efficiently for regulatory compliance; demonstrates skills necessary for proper documentation in the Electronic Medical Record; participate in quality improvement, continuing education, and other patient care programs established by the health center requirements for QuadMed and/or assigned client groups
  • Scans and imports records, forms, etc. as necessary
  • May perform occasional clinic nursing duties in the event of an employee illness or absence

Qualifications
Education:  

  • Requires a bachelor’s degree in nursing from an accredited college or university

Experience:

  • Five (5) to seven (7) years of experience working in a clinical setting
  • A minimum of three (3) years of  experience in clinical data analysis
  • A minimum of two (2) years of experience in care coordination, referral coordination, and/or population health management
  • Chronic Case Management experience preferred

Certificates, Licenses, Registrations: 

  • Requires a current, valid nursing license in the state of the position or compact state license required
  • Requires current BLS Certification; ACLS or PALS preferred


Knowledge, Skills & Abilities: 

  • Familiarity working in an electronic medical records system, preferably working with population health management programs, such as disease registries
  • Must have strong nursing skills, with ability to work collaboratively with members of a clinical team
  • Exhibit excellent communication (verbally and written) and interpersonal skills, especially working with diverse populations; ability to have crucial conversations with patients one-on-one or in group settings,  using a therapeutic and engaging approach to help change behaviors and lifestyles over time.
  • Ability to manage multiple tasks and organize time efficiently
  • In conjunction with clinic supervisor, delegate responsibilities to clinic staff (contact patient for follow-up, contact pharmacy to inquire about medication compliance, etc.)
  • Make recommendations to providers about care plan and promote additional services available to patients
  • Strong program-planning and marketing skills

Additional Company Information
We offer excellent benefits to eligible employees, including 401(k), holidays, vacations and more. In select states, patient care is provided by an independent physician-owned corporation.
Quad/Graphics is an equal employment opportunity employer. The Company’s policy is not to unlawfully discriminate against any applicant or employee on the basis of race, color, sex, sexual orientation, gender identity, religion, national origin, age, military or veteran status, disability, genetic information or any other consideration made unlawful by applicable federal, state, or local laws. The Company also prohibits harassment of applicants and employees based on any of these protected categories. 
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