Population Health Programs, RN

Mysemg; Northern (KY); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Southeast Primary Care Partners is seeking a Registered Nurse to support population health initiatives, focusing on high-risk patients and telephonic outreach using evidence-based guidelines. This role emphasizes care coordination across care teams and robust documentation in our EHR.

The RN will collaborate with providers, pharmacists, and medical assistants to ensure comprehensive patient care, while staying current with regulatory standards and disease management for chronic conditions.

Qualifications

• Over 3 years of experience in Care Management, HEDIS, STARS ratings, and population health initiatives.
• Experience in Electronic Health Record (EHR) documentation, preferably Allscripts/Veradigm.
• Registered Nurse license in Georgia or compact licensure.
• Bachelor’s degree in Nursing.

Responsibilities

• Utilize software for identifying high-risk patients and documenting care and interventions; use EHR for assessments and communication with patients’ primary care providers.
• Conduct telephonic outreach using Ring Central to assess patients and provide education, resources, and care coordination.
• Collaborate with providers, pharmacists, and medical assistants for comprehensive patient care.
• Integrate with partner practices to collectively achieve population health goals.
• Stay abreast of regulatory standards (HEDIS/STARs), care management practices, social determinants of health assessments, and disease management for conditions like diabetes, CHF, and COPD.

Skills

Care management

EHR documentation

Communication skills

Interdisciplinary collaboration

Education

Bachelor’s degree in Nursing

RN license (Georgia or compact)

Tools

Allscripts/Veradigm

EHR systems

RingCentral

Job description

All Jobs > Population Health Programs, RN

Join our dynamic team at Southeast Primary Care Partners! We are seeking high-energy, engaging nurses passionate about population health. This role plays a key part in transforming healthcare in the southeast by improving health outcomes for our high-risk patient population. The position involves extensive telephonic outreach, utilizing evidence-based guidelines to assess and intervene effectively.

Requirements

Key Responsibilities:

• Utilize software for identifying high-risk patients and documenting care and interventions. Also, employ EHR for assessments and communication with patients' primary care providers.
• Conduct telephonic outreach using Ring Central software to assess patients and provide education, resources, and care coordination.
• Collaborate with providers, pharmacists, and medical assistants for comprehensive patient care.
• Integrate with partner practices to collectively achieve population health goals.
• Stay abreast of regulatory standards (HEDIS/STARs), care management practices, social determinants of health assessments, and disease management for conditions like diabetes, CHF, and COPD.

Requirements:

• Registered Nurse in Georgia with a minimum of 3 years in care management (acute, post-acute, ambulatory care settings).
• Familiarity with discharge planning, post-acute services, DME, social determinants of health, and resource coordination.
• Capability to manage 250-300 patients monthly.
• Excellent communication, multitasking, escalation, and delegation skills.
• Proficiency in data interpretation, problem-solving, and implementing initiatives.
• Collaborative approach to identify and recommend improvements.

Minimum Qualifications:

• Over 3 years of experience in Care Management, HEDIS, STARS ratings, and population health initiatives.
• Experience in Electronic Health Record (EHR) documentation, preferably Allscripts/Veradigm.
• Registered Nurse license in Georgia or compact licensure.
• Bachelor’s degree in Nursing.

Key physical and mental requirements:

• Ability to lift up to 50 pounds
• Ability to push or pull heavy objects using up to 50 pounds of force
• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving
• Ability to travel to multiple locations to support business needs as required

FLSA Classification: Exempt

Southeast Primary Care Partners is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.