Population Health Nurse

Holy Cross Hospital Fort Lauderdale, FL

About the Job

Position Purpose:

Employment Type:

Full time

Shift:

Description:

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

*Collaborates with appropriate providers, facilities, external healthcare organizations throughout the continuum of care and communicates with an interdisciplinary team to develop and maintain positive working relationships while providing for the diverse needs of members and families.

*Functions as a coordinator and manager of a defined health population, with modifiable risks, across multiple care settings and for multiple physicians/health care providers or health plan counterparts.

*Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources.

*Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are member-centric, promoting quality and efficiency in the delivery of health care.

*Continually monitors member/family response to plan of care and revises the care plan as indicated.

*Provides self-management support with a focus on empowering the member/family to build capacity for self- care.

*Fosters a team approach and includes member/family as active members of the team. Takes the lead in ensuring continuity of care extends beyond ambulatory practice boundaries.

*Manages transitions of care when member transitions from one setting to another. Completes timely post-hospital/facility follow-up: Medication review, follow-up appointments, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.

*Supports the activities of identifying and evaluating members' needs inclusive of transition care planning and readmission prevention, in collaboration with the interdisciplinary team.

*Follows nursing process and implements systems of care that facilitate care coordination and close monitoring of high-and rising risk members. Aligns care management services to the needs of the population.

*Provides education, health coaching and engages members using motivational interviewing skills.

*Serves in an expanded healthcare role to collaborate with all interprofessional colleagues, and members /families to ensure the delivery of quality, efficient, and cost-effective health care services.

*Stays abreast of evidence, existing and emerging strategies regarding effective engagement and communication techniques, care management models and tactics, and behavior change tools and incorporate knowledge into clinical practice.

*Collaborates with health plan representatives to further mutual clinical and administrative outcomes, as applicable.

*Provides education, health coaching and engages members using motivational interviewing skills.

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.