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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Population Health Nurse (PHN) leads a population health team by providing clinical knowledge and experience to support performance in our value-based contracts. The PHN works cross functionally with others internally and externally to support data driven results. Uses patient outreaches, education and expertise to ensure success of care gap closure for ambulatory care through clinician and patient engagement.

Minimum Job Qualifications

• Licensure or other certifications: RN Registered Nurse License in GA

• Educational Requirements: Bachelor's Degree

• Minimum Experience: Minimum of 5 years experience with quality metrics/HEDIS measures to support performance in value-based quality programs.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements:

• Preferred Experience: Experience working in a CIN or ACO preferred.

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Excellent communication (verbal and written) and presentation skills, to provide superb, personalized customer service and to instill confidence and to advocate for patients; ability to explain required information to patients in a comprehensible manner

• Understanding of population health concepts related to quality metrics and value based contracts.

• Ability to develop strong, trusting relationships with leadership, physicians, pharmacists, and patients in the Value Based Programs

• Highly organized, work autonomously, self-motivated with the ability to adapt to various workspaces. Self-directed through multitasking and prioritizing.

• Proficient with Microsoft Office applications (Word, Excel, Outlook, PowerPoint)

• Other professional skills and qualities: strong attention to detail, dependability, empathy, focus on quality, goal oriented, ability to delegate and direct others.

• Must practice discretion and confidentiality as position deals with highly sensitive and private data

• Excellent problem solving and communication skills, who can thrive in an autonomous and evolving environment

• Understanding of complex health care systems, value based programs, care gaps, Quality Improvement, Medicare Stars, HEDIS measures and patient medical needs

Essential Tasks and Responsibilities

• Shall lead a team of population health coordinators in closing care gaps to maximize value-based opportunities tied to HP2 attributable lives

• Shall demonstrate strong people performance management that is able to prioritize work to drive results

• Builds rapport with patients, providers and clinical staff to identify strengths and barriers, promoting exceptional patient care while working to achieve success in meeting quality metrics.

• Support HP2 Quality Team through education and working through complex issues

• Utilize available databases, payer portals, and other data and analytic tools to assess patient activity and address barriers to care, when possible

• Leads and or participates in scheduled quality and payer meetings

• Participate in staff meetings, in-services, and other program-specific tasks and activities as required

• Works with committee members and staff to design and implement the annual QA plan for HP2 including the annual assessment process

• Analyze data to identify opportunities for process improvement and develop strategies to improve patient compliance

• Conducts telephonic outreach to patients to support closing care gaps

• Consult with patients and family members to discuss their gaps in care

• Educates the patient and their family about preventive health screenings while identifying barriers to care.

• Works in conjunctions with ambulatory care settings to communicate care gap needs and actions.

• Documents all patient data / actions / interactions in all appropriate areas as deemed.

• Interacts with other departments and other payers to identify and resolve care gaps.

• Refers to Care Manager as appropriate.

• Performs other duties as assigned within scope of practice

• Facilitates reporting of information from source systems using the most appropriate tools

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30% of time

• Standing/Walking: Occasionally 0-30% of time

• Pushing/Pulling: Occasionally 0-30% of time

• Intensity of Work: Occasionally 0-30% of time

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.