Registered Nurse, Population Health

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

Position Overview

Reporting to the Nurse Manager, Primary Care, the Population Health Nurse supports the organizations population health strategy by monitoring quality and population health dashboards, collaborating closely with Primary Care Providers (PCPs), identifying and addressing gaps in care, coordinating patient outreach, and overseeing key population health metrics. The Population Health Nurse partners with interdisciplinary teams to improve quality outcomes, enhance preventive care delivery, and support value-based care initiatives.

Reports to: Manager, Nursing

Principal Duties and Responsibilities

• Monitor quality and population health dashboards to identify care gaps and opportunities for improvement
• Oversee key population health metrics, including preventive care, chronic disease management, and value-based care measures
• Serve as the primary nursing resource for monitoring, validating, and improving performance on organizational population health and quality 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
• Establish patient care goals through education, information, and guidance for patients and families
• Develop partnership with service providers, families, and patients in addressing gaps in care and coordinate reosurces/outreach
• Ensure coordination and continuity of care, including engagement with community resources and family support
• Maintain close communication with the Primary Care team to ensure consistency in care planning
• Maintain accurate, detailed, and up-to-date reports and records
• Acquire and maintain knowledge of available patient services, insurance benefits, and reimbursement processes
• Act as a resource and advocate for patients, clinicians, and families to ensure appropriate care and services
• Assist patients in navigating access to MIT Health services and external specialists, including mental health resources
• Collaborate with the Primary Care nursing team as needed
• Stay informed on current research related to ambulatory nursing and care coordination, and contribute to program development
• Perform other duties as assigned

Minimum Required Education And Experience

• Graduate of an accredited nursing program. Bachelor’s degree required.
• Licensure: Current RN license in Massachusetts. CPR Certified
• Minimum 3 years of nursing experience in population health, ambulatory care, primary care, chronic disease management, case coordination or related clinical setting
• Demonstrated experience utilizing patient registries, quality dashboards, and population health tools to identify care gaps and implement interventions that improve patient outcomes
• Knowledge of preventive care guidelines, chronic disease management principles, risk stratification methodologies, and evidence-based clinical practice
• Experience collaborating with interdisciplinary care teams to achieve quality and patient care goals
• Strong analytical, communication, organizational, and time-management skills

Job number: 26172

Grade level: 9

Pay Range: $95,000 - $105,000, final salary determined by MIT’s compensation team based on the skills and experience of the person hired

• To comply with regulations by the Americans with Disabilities Act (ADA), the principal duties in job descriptions must be essential to the job. To identify essential functions, focus on the purpose and the result of the duties rather than the manner in which they are performed. The following definition applies: a job function is essential if removal of that function would fundamentally change the job.