Summary
Location
Vincennes
Type
full-time
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About this role
Job Summary:
The Population Health Nurse will work in collaboration with primary care providers and healthcare teams. Primary responsibilities will include the following:
- Identification of Medicare patients appropriate for Annual Wellness Visits & execute guided processes to complete the visit.
- Effectively coordinate & manage high-risk chronically ill patients through Chronic Care Management & Remote Patient Monitoring utilizing health coaching techniques to assist patients with self-management of their chronic diseases & lifestyle changes to mitigate health risk.
- Initiate Transitional Care Management coordinating efforts with post-acute providers (Home Health, PCP, Pharmacy, SNF etc.).
Essential Job Duties:
- Attend and actively participate in all ACO population health related trainings and meetings including advanced health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on-one meetings, as needed
- Works collaboratively with the ACO team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the provider; post reminders to secure that all co-morbidities are discussed and documented during AWV
- Attend and actively participate in all Value Based Contract meetings, trainings & patient outreach
- Stratify patient population according to risk score. Effectively and efficiently manage patients with multiple chronic diseases; Identify patients appropriate for Chronic Care Management (CCM). In collaboration with the PCP, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
- Ensure sharing of positive patient stories or compliments involving care team efforts
- Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/visits, CCM encounters, navigate care for patients enrolled in RPM
- CMA oversight as directed by Quality & Care Coordination Manager
Secondary Job Duties That May be Reassigned:
- Perform other related duties as directed by Quality & Care Coordination Manager & Executive Director, Good Samaritan Physician Network
Thank you for your interest in employment at Good Samaritan Hospital. Please provide all information requested to assure that all your qualifications are fairly considered for current or future vacancies. Your application will remain in our active files for six months. After six months, re-application is necessary. The submission of this application does not automatically result in an employment interview or job offer.
Other facts
About Good Samaritan
For more than 100 years, Good Samaritan has been a health care leader in southwestern Indiana and southeastern Illinois. Located in historic Vincennes, Good Samaritan is a 158-bed community health care facility with over 1,800 employees and a commitment to delivering exceptional patient care.
Good Samaritan offers a broad range of medical services as well as some of the most progressive technology available today. The Gibault Memorial Tower, opened in 2015, provides our patients, their families and our entire community an environment where the highest quality of care is provided. An array of services and staff are ready to greet patients with medical expertise, cutting-edge technology and big hearts. The tower has five floors, each with a focus: Cardiology and Clinical Decision, Intensive Care, Pediatrics and Medical Surgery, Joint Replacement and Medical Surgery, and Women’s Health and Oncology.
The hospital also has a state-of-the-art Same Day Surgery Center, with surgical suites designed with input from the hospital’s physicians.
The Cancer Pavilion is a 25,000-square-foot comprehensive oncology care center, featuring one of the most advanced methods for delivering radiation therapy, a linear accelerator with IMRT. The Pavilion also has 12 fully equipped infusion suites and other amenities for patients and families.
Good Samaritan is proud that generations of families have chosen us as their preferred health-care provider, allowing us to be the first, best place in health care.
Mission: Provide excellent health care by promoting wellness, education and healing through trusting relationships.
Vision: To be the regional center of excellence in health care to support the communities we serve.
Our Promise: We promise to treat you like family by delivering compassionate, high-quality care throughout your journey.
PRIDE Values
Patient | Respect | Integrity | Dignity | Excellence
What you'll do
- The Population Health Nurse will collaborate with primary care providers to manage high-risk patients and coordinate care. Key duties include conducting Annual Wellness Visits, Chronic Care Management, and Transitional Care Management.
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