POSITION SUMMARY

The Population Health and Triage nurse works collaboratively with multidisciplinary care team across the continuum of care to provide care and disease management to high-risk patients identified in the ambulatory setting, focusing efforts on patient outreach and coordination of care for a panel of patients to achieve optimal outcomes and promote wellness.  Provides triage care and assist the patients in obtaining an appointment or provide advice.

This position is non-exempt and will work office hours Mon-Fri. After successful completion of training, remote work will be available 1-2 days per week.

Essential Duties

The Population Health and Triage Nurse will be responsible for the following:

• Determines if the patient needs to be seen immediately at the Emergency Department, should schedule an appointment in the primary care office, or if their concerns can be managed over the phone.
• Demonstrates excellent critical thinking skills and reliable nursing judgement.
• Demonstrates ability to correctly recognize high, routine, and low priority messages and manages each type according to triage services protocols and workflows.
• Manage population health initiatives to support the practices’ success in providing value-based care.
• Identify and recruit appropriate patients for care management in collaboration with the medical staff.
• Develop patient centered care plans in collaboration with medical staff members, with particular focus on chronic disease management, social determinants of health, transitions of care and advanced care planning.
• Implementation of care plans
• Educate the patient on their medical conditions and medications to build and empower self-management skills.

• Uses assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
• Conducts or facilitates targeted outreach efforts to a defined panel of high-risk patients (chronic illness, lack of social support, readmissions, ED visits, etc.) to ensure timely and efficient care delivery across the continuum of care.
• Utilizes technological tools (registries, patient lists, etc.) to manage populations.
• Conducts comprehensive clinical assessments that include disease-specific, medical, behavioral, pharmacy, social and end of life needs of each patient.
• Actively involves the patient and family regarding coordination of their care. Shares this information with the healthcare team, patient, and family.
• Works collaboratively with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes.
• Monitor patient compliance with plan of care. Performs reassessments regarding patient progress toward goals and updates plan of care as appropriate. 
• Ensures care gaps are closed around specialty disease/chronic disease. Coordination: Often serves as primary patient contact for team related to condition. Facilitates access to services.
• Organizes tasks and responsibilities around the patient and family needs. Serves as the liaison with patients and families to physicians and clinical staff.
• Assists in managing transitions of care across care settings, ensuring optimal communication, and planning of care.
• To ensure the right to each patient, to reach her/his highest level of independent wellness through the support of post hospital and community services as needed.
• Focuses the plan of care and services on the patient/family needs, preferences and advocacy using multidisciplinary approach.
• Provides a continual system of communication through documentation and re-evaluation of the patient considering the anticipated needs at the present level of health care delivery and thereafter.
• Coordinates the discharge planning with the discharge planner nurse and attending physician and assists connecting patient and family with appropriate community resources.
• Provides a consistent method of patient care management, which maximizes the hospital length of stay thereby decreasing the risk of readmission’s related to noncompliance and inappropriate utilization of resource.
• Adhere to HIPAA requirements.

QUALIFICATIONS & REQUIREMENTS

Education and Experience

• Associate/bachelor’s degree in nursing (Required)
• Minimum of five years’ experience in nursing (Preferred)

• BLS and ACLS (Preferred)
• Population Health or ACO experience (Preferred)
• Triage Experience (Preferred)
• Knowledge and experience using EPIC EHR (Preferred)
• Proficient knowledge and experience using computer applications (Windows, MS Office, etc.)
• Knowledge of external regulations that affect the area of responsibility.

Required Licenses

• Registered Nurse (RN)

Skills, Abilities, and Knowledge

• Knowledge and experience of rules and regulations regarding the medical staff
• Strong oral and written communication skills
• Demonstrates a high degree of commitment to customer service excellence
• Ability to work effectively with internal and external stakeholders, building strong relationships
• Ability to perform tasks both collaboratively and independently
• Maintains confidentiality of information and privacy compliance

Travel

• Minimal travel may be required up to 5%

COMPETENCIES

• Initiative – Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Takes independent actions and calculated risks; Looks for and takes advantage of opportunities; Asks for and offers help when needed.
• Judgment – Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Quality – Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Professionalism – Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Safety and Security – Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly.
• Teamwork – Balances team and individual responsibilities; Exhibits objectivity and openness to other views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Supports everyone's efforts to succeed.
• Verbal Communication –Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
• Written Communication – Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

SUPERVISOR RESPONSIBILITIES

• N/A

PHYSICAL REQUIREMENTS

• This position is subject to sedentary work, exerting up to 15 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involved sitting most of the time. Walking and standing are required occasionally.
• This position is subject to the following physical activities: talking, hearing, and the use of hands, wrists, or fingers in repetitive motions.

Physical Activities

• This position is subject to the following physical activities: talking, hearing, and the use of hands, wrists, or fingers in repetitive motions.

Visual Acuity

• The worker is required to have close visual acuity to perform an activity such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; expansive reading; visual inspection involving small defects, small parts, and/or operation of machines (including inspection); using measurement devices; and/or assembly of fabrication of parts at distances close to the eyes.

Working Conditions

• This position operates in a professional office environment. This role routinely uses standard office equipment.

Johnson Memorial Health Services (JMHS) is an Equal Opportunity Employer. In compliance with the Americans with Disabilities Act, JMHS will provide reasonable accommodations to qualified individuals with disabilities and encourage prospective and current employees to discuss potential accommodations with the employer. The above statements are not intended to be an all-inclusive list of job duties, responsibilities, skills, or abilities required to perform this job. Rather, they are intended only to describe the general nature of the position. Johnson Memorial Health Services reserves the right to modify position descriptions as necessary to meet the organization's needs.