• Population Health Nurse

    Posted: 12/05/2021

    Title:  Population Health Nurse
    FTE:  1.0 FTE (40 hours/week)
    Schedule:  Monday-Friday between the hours of 8:00am - 5:00pm
    Holiday Rotation:  None
    Weekend Rotation:  None
    On Call Requirements:  None
    The Population Health Nurse is responsible for the coordination of SPH’s Population Health services with diverse job functions designed to meet specific contractual and program related requirements. This role focuses on improving the health status and care for individuals with chronic conditions; potentially complex medical, mental health, and psychosocial issues; and implementing the case management processes for this enrolled population.  In addition, this position focuses on population health/chronic care management workflows in primary care clinics and across the SPH spectrum of care.

    1. Assist and supports development of population health care model at SPH.  Actively partner with primary care clinics, Social Workers/RN Case Manager, Population Health Program Manager, and Outreach CMA to proactively identify and resolve potential barriers and constraints.
    2. Assist in evaluating patient health status, facilitates the proper plan of care with the care team and manages the implementation of nursing services to meet the patient’s individual health needs. 
    3. Engage with a wide variety of stake holders to develop a portfolio of population health/chronic care management model programs that provide a coordinated, comprehensive system of care, and works with other team members to coordinate and implement needed processes. 
    4. Act as a patient advocate, as a resource to patients/families and staff, and as a leader of the interdisciplinary team with clinical focus and priority for care continuity.  
    5. Serve as a liaison between the patient, staff and physician to establish and implement a plan of care for each patient.  
    6. Work closely with other members of the team and leadership to continue to assess and develop the program, and assess needs with clinical focus. 
    7. Responsible for identifying and assisting with coordination of learning modules to support on-going development and evolution of program.
    8. Ensure adherence to population health care model core standards, support development of timelines to achieve expectations and meet goals.
    9. Assess patients for potential needs in a timely manner and identify those in need of chronic care intervention.  Follow patients through the continuum of care to improve preventative care and decrease readmission rates.
    10. Identify patients with high risk or high cost care, coordinates interventions, and facilitates appropriately in support of patient needs and clinician advisement.  
    11. Acts as liaison between teams and departments to ensure deliverables are completed on time and within SPH high quality standards.
    12. Evaluate, plan, coordinate, and revise patient continuity of care in order to optimize success in meeting care plan objectives.
    13. Communicates and coordinates with members of appropriate team such as primary care, continuum of care or other disciplines as it pertains to patient follow up and documentation.
    14. Able to manage databased reports as tools to execute follow up to support defined model.
    15. Continued contact with patients with chronic diagnoses to assist with life style changes as needed to prevent recurrence or exacerbation of chronic illness. 
    16. Meet with patient and family to assist with disease management planning. If need, work with care manager/social worker to close disease management care gaps.  
    17. Ensure a plan for psychosocial patient and family needs is developed.
    18. Coordinate and lead family conferences and/or multidisciplinary care conferences as needed.
    19. Document accurate assessments and interventions in patient’s electronic medical record in an effective and timely fashion.

    • Required:  Associate Degree in Nursing.
    • Preferred:  Bachelor’s degree in nursing (BSN) or Master’s Degree in nursing (MSN)
    • Required:  Minimum of 2 years of nursing experience
    • Preferred:  Two or more years of experience in population health with clinic and hospital integration.
    Licenses and Registrations
    • Required:  Current State of Wisconsin licensure as a Registered Nurse
    • Preferred:  None
    • Required:  Basic Life Support (BLS) – within 3 months of hire
    • Preferred:  None 
    1. Competitive health and dental insurance options
    2. Flexible paid time off to balance work and life
    3. Retirement plan with immediate vesting and employer match
    4. Free membership to our state-of-the-art fitness facility
    5. Generous tuition reimbursement
    6. Employer provided life and disability insurance
    7. Free parking at facility
    Interested in an extraordinary career? Click the link to apply.