Population Health RN (FT)

Family-Health-West; Grand Junction (CO); On-site; USD 40,000 - 58,000; Full time

Benefits offered by this job

Full benefits package

403(b) with 4% match

Telemedicine options

Job summary

Family Health West is seeking an experienced Registered Nurse to play a key role in population health initiatives within western Colorado. You will collaborate with primary care teams to optimize annual wellness visits, care plans, and chronic disease management, while supporting patient counseling and care coordination across the practice.

The ideal candidate has a nursing degree, RN licensure, BLS certification, and 3 years of related healthcare experience in population health or ambulatory

Qualifications

• RN license required
• BLS required; Quality Improvement Certification preferred
• Three (3) years of related healthcare experience in population health or ambulatory care setting

Responsibilities

• Attend and participate in population health trainings, meetings, and certifications.
• Maintain reliable and punctual attendance.
• Communicate information to the team as needed.
• Track Annual Wellness Visit scheduling and review patient records to identify care gaps before provider visits; post reminders for completing comorbidities.
• Establish competencies related to AWV screenings (PHQ-9, TUG, Mini-Cog) and train the care team to perform them.
• Establish counseling resources for obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety, and advanced care planning.
• Stratify patient population to manage multiple chronic diseases and determine visit frequency; maximize use of clinical staff for non-face-to-face contact.
• Develop care plans with patients and families; monitor adherence and progress; adjust as needed.
• Participate in daily huddles with primary care providers to identify scheduling opportunities and patient needs.
• Collaborate with practice leaders to implement internal tracking systems (patient panels, AWV scheduling, CCM encounters).
• Collaborate on group projects and work autonomously; implement empanelment for patient assignment to providers.

Education

Bachelor's degree in Nursing, or Associate's Degree in Nursing

Job description

You belong here! At Family Health West, you're more than an employee, you're family.

When you enter our facility, you know it's Family Health West because, well, the color speaks for itself. You'll be part of a team that strives to bring color to care in a vibrant environment by creating fun, effective treatment programs helping to empower and inspire our patients while providing the tools and care they need to achieve their wellness goals.

When we say you'll do what you love, we mean it! Welcomed by open arms and warm smiles, you'll join a team that encourages professional growth. We are sure to put on our listening ears when you share new ideas and approaches to care because that's what got us to the top! You'll wear your badge proudly, knowing that you contribute each day, to providing care that is unmatched, in western Colorado.

About Family Health West

Our roots go deep -- founded by the community in 1946, it's no wonder our hospital feels like coming home. We were built from the ground up with the hands of our own community, a labor of dedication and hope by our people, for our people, for the future.

At Family Health West we go beyond what corporate hospitals deliver, we’ve created a culture of prosperity where warmth, passion, and care flourishes. As we focus on continually improving outcomes for patients, our network of healthcare providers includes a 25-bed critical access hospital, one of the largest rehab providers in western Colorado, outpatient surgical services, specialty clinics, emergency services, skilled nursing, and assisted living facilities.

Nestled at the base of the Colorado National Monument, Family Health West has an outdoor paradise at your back door. The community culture is fitting for outdoor lovers, bikers, hikers, or those just simply soaking in the panoramic views.

Essential Functions

• Attend and actively participate in all Family Health West population health related trainings and meetings including advanced health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on‑one meetings, as needed
• Reliable and punctual attendance is essential; expected to be at job as scheduled each scheduled day.
• Communicate necessary information to others as appropriate.
• Works collaboratively with the FHW team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the provider; post reminders to ensure that all comorbidities are discussed and documented during AWV.
• Establish competencies related to AWV screenings such as PHQ-9, TUG and Mini-Cog and assists FHW to train care team to perform these screenings.
• Establish counseling services/resources within the practice to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety and advanced care planning.
• Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases; determine frequency for provider visit and Chronic Care Management (CCM) encounters; maximize use of qualified clinical staff within the care management team to provide appropriate non‑face‑to‑face patient contact.
• In collaboration with the primary care providers, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to the care plan and progress toward goals and facilitate changes as needed.
• Participate in daily huddles with primary care provider and care team; identify scheduling opportunities, special needs for patients with appointments that day, patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments requiring rescheduling; ensure sharing of positive patient stories or compliments involving care team efforts.
• Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow‑up calls/visits, and CCM encounters.
• Must have the ability to collaborate as a group on projects as well as work autonomously.
• Collaborate with practice leaders to establish a method for assigning patients into a panel listing by provider that is routinely utilized for scheduling purposes; utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers.

Education

Education: Bachelors degree in Nursing, or Associates Degree in Nursing

Licenses

Licenses: Registered Nurse required

Certifications

Certifications: BLS required, Quality Improvement Certification preferred.

Experience

Experience: Three (3) years of preferred related healthcare experience in population health, or in acute case setting, ambulatory care, home health, or physician practice.

Wage starts at $35.57

Immunizations required for employment

FHW offers a full benefits package including:

• FOR ALL EMPLOYEES:
• Employee Assistance Program
• 403 (B) with 4% match from FHW and zero day vesting schedule
• FOR FULL TIME EMPLOYEES WORKING AT LEAST 30 HOURS A WEEK
• Medical Plan Options:
• I. PPO plan with copay/coinsurance and lower deductible
• II. High Deductible Health Plan with the option for a Health Savings Account.
• III. Telemedicine includes in both plan options.
• Dental
• Vision
• Life Insurance/ Accidental Death and Dismemberment Insurance
• Disability Insurance with a Short and Long Term Option.
• Critical Illness and Accident Plans
• Cafeteria Options: Health Reimbursement/ Flex Savings
• A host of other options to include: Pet Insurance, Identity Protection, Travel protection.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.