Community Health Center Hiring For Population Health Nurse at Middletown, CT, United States Full Time

Job Description

Summary:
Community Health Center, Inc. (CHC), with offices in Connecticut, Colorado and California, is one of the country’s most creative and dynamic providers of primary medical, dental, and behavioral health services, and a leader in practice-based research, health professionals training, and use of innovative technologies to advance health and healthcare. CHC is designated as a federally qualified health center and a patient-centered medical home by HRSA, the Joint Commission, and NCQA, respectively. We deliver more than 500,000 patient visits per year from primary care hubs and community clinics across the state of CT, all connected by technology and common standards for quality. We employ several hundred medical, dental, and behavioral health providers who are engaged in practice, teaching, and research. Our Weitzman Institute is devoted to research and practice transformation and is recognized around the country as one of the premier research institutes focused on improving health care and health outcomes for special and vulnerable populations. In addition, the organization has developed three wholly owned subsidiaries from the original pilot developments within the Weitzman Institute: the National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC), the National Institute for Medical Assistant Advancement (NIMAA), and ConferMED.
:
The Population Health Nurse supports the mission of CHCI to improve health outcomes by focusing attention on groups of patients as well as individual patients identified as having or likely to have gaps in care, adverse health outcomes, or suffer from health inequities related to social, racial/ethnic, environmental, and economic determinants of health. At the direction of the population health manager, the Population Health RN also supports the objectives of CHCI’s value based care contracts to provide new, innovative, or additional monitoring, support and interventions to achieve outcomes whose value exceed the cost of the intervention. This position reviews and monitors data sets such as care gap reports by population, missed opportunities for prevention by panel, and follow up of transitions in care. Along with the population health manager, this position works directly with health plan representatives, both public and private, to ensure that patient attribution lists are timely and up to date and that quality measures are documented, monitored, and reported.
Required Qualifications

• Current RN Licensure in the state of Ct.
• Minimum BSN or bachelor’s degree in another field and post-bachelor’s certificate in nursing.
• Prior experience in population health, quality improvement, or care coordination preferred
• Prior experience with use of electronic health record systems required
• Prior experience in telehealth care preferred
• Proficiency with Microsoft Office products, specifically Excel, required
• Ability to work independently and meet deadlines
• CT Driver’s license

Job Responsibilities
The primary responsibilities for this role include:

• Reviews care gap reports on a regular basis, including both those generated from CHCI’s internal data and those provided by insurers and coordinate resolution directly with patients or indirectly with primary care team members.
• Engage patients in care coordination and management as needed, directly or through coordination with assigned primary care RN.
• With supervisor, plan agenda for and participate in population health and value based care committee, and carry out interventions developed by the committee.
• Prepare and submit reports to insurers, both public and private, on outcomes of population health initiatives.
• Train primary care staff on initiatives such as MAWV or CPE.
• Develop procedures for implementing new initiatives that arise from value based care/population health arrangements such as Initial Physical Preventive Exams/Welcome to Medicare, Annual Wellness Visits and Complex Care Management.
• Provide education to both patients and staff, as indicated, concerning population health and value based care initiatives.

COMMUNICATION SKILLS
Excellent oral and written skills are required. This position is highly involved with leadership, staff, providers, clients, colleagues, outside vendors and the community.
Technical skills
Must have above average proficiency in use of Excel. Expertise in PowerPoint, Visio, or Tableau highly desirable.
Location:
Middletown – Weitzman Building
City:
Middletown
State:
Connecticut
Time Type:
Full time