Job Summary :

Maintains responsibility and oversight of a team for assessment, planning, and implementation and evaluation of health services of a specific population across the continuum of care, including pre- / post-hospitalization. Evaluate, support and participate in a significant level of facilitation in multidisciplinary illness and treatment plan of care collaboration. Facilitate education, training, processes and outcomes while leading and coordinating the population health team, collaborating with providers, the multidisciplinary team, and the community. Foster staff development opportunities that promote and maintain professional competencies. Serves as a liaison and resource between providers and other health care teams and the community to support the quadruple aim. Reviews, analyzes, and reports data and implements quality improvement initiatives focusing on readmissions, complications, clinical recommendations, and self-management. Facilitates interdisciplinary collaboration to measure and assess processes and outcomes, and proactively identify potential solutions. Collaborates with community providers and employed providers and care navigators to identify high-risk admissions, screen re-admissions, facilitate care planning, impact disease management, and work with those teams to optimize the continuum of care plan of health care services. Supports Health Care reform and Payer Initiatives. Supports the Manager and Director of Population Health in care team responsibility, oversight and management.

Qualifications :

Bachelor's Degree from a recognized college or university required; Master's Degree with Clinical background preferred (MSN, MHA, MBA) preferred. Current RN license to practice in NC (NC license or multi-state (compact) license). Minimum of 5 years of nursing experience in an acute care hospital required. 2 years of experience or knowledge in Care Coordination or post-acute care role required. Thorough knowledge of continuum of care needs, specific disease process, and post-acute management. Broad knowledge of community health concepts and services is required. Ability to work with a multidisciplinary team and communicate with all members of the team. Demonstrates an ability to plan and coordinate varied activities and work with senior and mid-level managers as well as physicians. Demonstrates excellent skill and ability for analytical thinking, problem-solving, and has excellent communication skills (written and oral). Promotes knowledge and application principles of clinical documentation. Demonstrates strong project management skills, utilizes data management skills, demonstrates the ability to organize and prioritize workload, works in collaboration with a variety of individuals. Performs independently and works well within a team. Good critical thinking skills that result in positive patient outcomes. EOE AA M/F/Vet/Disability #IND123

Location:

CaroMont Health •

Population Health-Specialty Schedule:

Full Time, 0830-1700