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Population Health RN - VMG

Virtua Health • Full-time • Marlton, New Jersey, United States • 1w ago

At Virtua Health, we exist for one reason – to better serve you. That means being here for you in all the moments that matter, striving each day to connect you to the care you need. Whether that's wellness and prevention, experienced specialists, life-changing care, or something in-between – we are your partner in health devoted to building a healthier community.

If you live or work in South Jersey, exceptional care is all around. Our medical and surgical experts are among the best in the country. We assembled more than 14,000 colleagues, including over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques to provide exceptional care close to home. A Magnet-recognized health system ranked by U.S. News and World Report, we've received multiple awards for quality, safety, and outstanding work environment.

In addition to five hospitals, seven emergency departments, seven urgent care centers, and more than 280 other locations, we're committed to the well-being of the community. That means bringing life-changing resources and health services directly into our communities through our Eat Well food access program, telehealth, home health, rehabilitation, mobile screenings, paramedic programs, and convenient online scheduling. We're also affiliated with Penn Medicine for cancer and neurosciences, and the Children's Hospital of Philadelphia for pediatrics.

Location:

Lippincott - 301 Lippincott Drive

Employment Type:

Employee

Employment Classification:

Regular

Time Type:

Full time

Work Shift:

1st Shift (United States of America)

Total Weekly Hours:

Additional Locations:

Job Information:

Job Summary:

Supports care coordination efforts for adult patients with moderate to complex illness, in the primary care setting, under minimal supervision. In partnership with the practice leadership team, including Clinicians, LCSWs, CBHMs and Practice Manager leads care management within the team through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.

Position Responsibilities:

Collaborates with practice leadership to lead practice transformation efforts and population health initiatives.

Collaborates with Practice Team to execute Daily Clinical Huddle: Reviews General Risk Scores for patients on the schedule, ED / IP tracking and follow up, Gaps in Care etc..

Leads care coordination efforts:

Oversight for Practice Risk Stratification.
Transitions of Care: Manages outreach, scheduling and follow up.
Collaborates with other case/disease managers as applicable.
Coordinates & performs Medicare Annual Wellness Visits.

Coordinates Care Management Efforts:

Creates & Reviews Care Plans with patients and family members, in order to provide Episodic and/or longitudinal care management.
Coaches the patient /care giver to meet patient centered individual plan of care goals.
Assesses health literacy of patients, and supports Medical Assistants with skill development for patient assessment.
Leads health coaching and motivational interviewing efforts; supports Medical Assistants with skill development.
Develops and implements patient education materials.
Maintains a list of local self-management support resources.
Coordinates with social worker with regard to community resources.

Serves as a clinical resource to practice staff.

Other duties as assigned.

Position Qualifications Required:

Required Experience:

1-3 years of experience in care coordination. Experience working in physician practice preferred.

Required Education:

Graduate of an accredited school of nursing, BSN preferred

Training / Certification / Licensure:

Must have current NJ license, current CPR certification.

Bilingual Spanish/English preferred.

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