Population Health Nurse: Care Quality & Coordination

MIT Health; Cambridge (MA); On-site; USD 95,000 - 105,000; Full time

Job summary

MIT Health in Cambridge, MA is seeking a Population Health Nurse to monitor quality dashboards, identify care gaps, and coordinate outreach in support of value-based care initiatives.

The role partners with Primary Care Providers and interdisciplinary teams to improve outcomes, manage chronic disease and preventive care, and guide patients and families through education and navigation of services.

Qualifications

• Graduate of an accredited nursing program with a Bachelor’s degree required.
• Licensure: Current RN license in Massachusetts; CPR certified.
• Minimum 3 years of nursing experience in population health, ambulatory or primary care.
• Experience using patient registries and dashboards to identify care gaps.
• Knowledge of preventive care guidelines and chronic disease management.
• Experience collaborating with interdisciplinary care teams to meet goals.
• Strong analytical, communication, organizational and time-management skills.

Responsibilities

• Monitor quality and population health dashboards and identify gaps for improvement.
• Oversee key population health metrics including preventive care and chronic disease management.
• Act as the primary nursing resource for monitoring performance on population health metrics.
• Collaborate with PCPs and interdisciplinary teams to improve patient outcomes.
• Conduct patient outreach and care coordination activities.
• Analyze quality performance trends and prepare reports.
• Support value-based care and quality improvement initiatives.
• Educate patients and families to establish care goals and guide services.
• Develop partnerships with providers, families and patients to address gaps in care.
• Ensure coordination and continuity of care with community resources and family support.

Skills

Population health

Nursing

Data analysis

Care coordination

Communication

Project management

Education

Bachelor's degree in Nursing

Tools

Quality dashboards

Population health tools

EHR systems

Job description

MIT Health in Cambridge, MA is seeking a Population Health Nurse to monitor quality dashboards, identify care gaps, and coordinate outreach in support of value-based care initiatives.

The role partners with Primary Care Providers and interdisciplinary teams to improve outcomes, manage chronic disease and preventive care, and guide patients and families through education and navigation of services.