Population Health Nurse - CVCH : Job Details

Job SummaryThe Population Health Nurse's primary job function is to support the mission of CVCH by collaborating with the care teams to improve the health of the population we serve. Primary responsibilities include identification of Medicare/Medicaid patients appropriate for Annual Wellness Visits and executing guided processes to complete the visit. They will also effectively coordinate and manage high risk chronically ill patients through Chronic Care Management utilizing health coaching techniques to assist patients with self-management of their chronic diseases and life-style changes to mitigate health risk. Other duties may also include assisting with other programs to include Transitional Care Management, ER utilization, coordinating efforts with Post-Acute Care Providers (Skilled Nursing Facilities and Home Health) or integration of Behavioral Health Services.Job Specific Competencies1. Develop a process to track Annual Wellness Visits (AWV) scheduling to ensure that patients records are reviewed to identify care gaps prior to visit with the provider. Post reminders to secure that all co-morbidities are discussed and documented during AWV.2. Establish competencies related to AWV screenings such as PHQ-9, TUG, and Mini-Cog and train care team to perform these screenings as needed.3. Identify or establish counseling services/resources within CVCH to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety and advanced care planning.4. Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases. Determine frequency for provider visit and CCM encounters. Maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to face patient contact.5. In collaboration with the primary care provider, develop a care plan based on mutual goals with the patient and family. Monitor patient adherence to care plan and progress towards goals and facilitate changes as needed.6. Participate in daily huddles with care teams. 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. Ensuring sharing of positive patient stories or compliments involving care team efforts.7. Collaborate with operational leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visits, transition of care follow-up calls/visits, CCM encounters.8. Collaborate with operational leaders to establish methods 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.9. Attend and actively participate in all Caravan population health related trainings and meetings including advance health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on-one meetings as needed.General Duties and Responsibilities1. Performs other duties and tasks as assigned by supervisor.2. Expected to be prepared to start shift at scheduled time, meet attendance standards, and work the hours necessary to perform the essential functions of the job.3. Follows all safety policies and general housekeeping practices. Ensures the area and its equipment and supplies are neat, clean, safe and utilized appropriately at all times, and participates in emergency drills.4. Demonstrates sound work ethics, flexible, and shows dedication to the position and the community.5. Demonstrates a positive attitude, is respectful, and possesses cultural awareness and sensitivity toward clients and co-workers.6. Keeps customer service and the mission of the organization in mind when interacting with all clients, co-workers, and others.7. Employees are expected to embrace, support and promote the core values of respect, integrity, trust, compassion and quality which align with the CVCH mission statement through their actions and interactions with all patients, staff, and others.8. Conforms to CVCH policies and Joint Commission and HIPAA regulations.Job Specifications1. Education: Associates or Bachelors degree in Nursing required.2. Certification/Licensure: Current RN license for Washington State required.3. Experience: Minimum of three (3) years direct patient care required, provider practice or clinic health setting preferred:a. Experience with Care Coordination, Case Management, Home Health or Behavior Health preferred.b. Experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.c. Experience with health IT systems and data reports preferred.4. Essential Technical/Motor Skills: Knowledge of computer applications and equipment related to work. Must have basic computer and keyboarding skills and have the ability to enter data within company's computer system to include strong knowledge in MS Word/Excel; must demonstrate manual dexterity. Exhibit strong customer service skills, strong process improvement background.5. Interpersonal Skills: Strong interpersonal and communication skills and the ability to work effectively with other staff, management and patients. Demonstrated skill in developing and maintaining productive work teams. Ability to demonstrate personal integrity in all interactions.6. Essential Physical Requirements: This job is performed mostly in a typical inside, office environment. Essential physical requirements of this job include: light physical effort; repetitive motions of wrists, hands, and/or fingers; standing, walking, lifting, reaching, kneeling, bending, stooping, pushing, and pulling; frequent sitting; lifting and/or moving items up to 50 pounds, with assistance as needed; ability to read forms and computer screens and to read correspondence and other documents.7. Essential Mental Abilities: Possesses strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate to patients with complex medical, emotional and social needs. Ability to work in a high-volume caseload environment and deal effectively with rapidly changing priorities. Ability to make decisions in line with state and federal regulations; ability to read, comprehend, and analyze documents, regulations, and policies; ability to prepare and submit complete and succinct documents necessary to the job. Ability to assess and evaluate, have attention to detail. Knowledge of auditing and compliance procedures, quality assurance and improvement practices, understanding of the elements of sponsored clinical protocols including consent forms, and reporting requirements. Problem solving and analytical skills are required with a heavy emphasis on detailed analysis of information to support actions.8. Essential Sensory Requirements: Essential sensory requirements include the ability to: read computer keyboard, monitor, and documents; prepare and analyze documents; read extensively; see, recognize, receive and convey detailed information orally, by telephone and in person; convey accurate and detailed instructions by speaking to others in person and by telephone.9. Exposure to Hazards: Worker is subject to inside environmental conditions on a frequent basis with moderate noise. Typical working conditions found in most administrative work areas. Worker has contact with consumers and other staff and may be exposed to medical conditions presented by them.Blood/Fluid Exposure RiskCategory III1. Tasks involve no greater exposure to blood, body fluids, or tissues than would be encountered by a visitor. Category I tasks are not a condition of employment.Age Specific CompetencyPosition does not involve patient care. Position will demonstrate general knowledge and skill to effectively communicate and provide safety measures to all life cycles.Benefits*Coverage below based on a 1.0 FTE; Medical, Dental, Paid Leave, Holidays are prorated based on FTEBenefit:Coverage:Effective:Medical Premera (Self Insured) Preferred Provider Employee covered - $60.00 per monthDependents covered - please refer to the benefits Guide 2025 for ratesFirst of the month following the first date of employment.DentalWashington DentalEmployee covered - 100%Dependents covered - 50%First of the month following the first date of employment.Paid Leave120 hours - Year 1136 hours - Year 2Each year after that employee will accrue 8 hours of PTO each year, on their anniversary date, until they reach a maximum of 208 hours at 10+ years.Paid Leave may be used immediately for sick leave and after 3 months employment for vacation. Maximum accrual cap of 320 hours; hours in excess of 320 hours will automatically transfer into the employees EIB. Extended Illness Bank (EIB)Allows for maximum accrual of 200 hoursPTO hours in excess of 320 will transfer into EIB. Employees are eligible to use EIB hours after at least 3 consecutive scheduled working days of PTO (max 24 hours) which have been used for a personal illness and/or a qualifying event under FMLA or the WA Family Care Act. Holidays88 hours related to:• New Year's Day• Memorial Day• 4th of July• Labor Day• Thanksgiving Day• Day after Thanksgiving• Christmas Eve• Christmas Day• 3 Diversity DaysHolidays are calculated as 8-hour days if full time, 1.0 FTE, and paid based on the calendar year (January 1 through December 31). Holiday hours will be added to the employee's timecard automatically. If an employee is part-time, as documented in our HR/Payroll system, Holiday hours will be pro-rated. If an employee starts after the calendar year has begun, holiday hours will be prorated based on remaining holidays in the calendar year and diversity days will be prorated as outlined below:• Jan 1- April 30: 3 diversity days (24 hours if 1.0 FTE)• May 1 - August 31: 2 diversity days (16 hours if 1.0 FTE)• Sept 1 - Dec 31: 1 diversity day (8 hours if 1.0 FTE)Please refer to the Paid Leave policy for additional details.403(b) Retirement PlanLincoln Financial150% CVCH match up to 3% of the employee's contributionImmediately. Vesting schedule:20% at 2 years, 50% at 3 years, 60% at 4 years, and 100% at 5 years.Employee Assistance Program Mutual of OmahaFree short-term counseling for employee and familyImmediately. Call 800-###-####Long-term Disability Mutual of OmahaEmployee Only (variable)First of the month following the first date of employment.Benefit:Coverage:Effective:Basic Term Life Mutual of OmahaEmployee Only (1x annual salary, up to $200,000)First of the month following the first date of employment.Group Accidental Death and Dismemberment (AD&D) Mutual of OmahaEmployee Only (1x annual salary, up to $200,000)First of the month following the first date of employment.Supplemental Term Life Mutual of OmahaEmployee / Spouse / Dependent(s)First of the month following the first date of employment.Voluntary AD&D Mutual of OmahaEmployee / FamilyFirst of the month following the first date of employment.Health Reimbursement Arrangement RedQuoteReimbursement for out of pocket expenses for services received at CVCH (medical, dental, and prescription) by employees and their dependents enrolled in our medical plan. Up to $750 per family per year.First of the month following the first date of employment.Flex Plan: Medical RedQuoteFlex Plan: Maximum $3,300 per yearDirect Deposit availableFirst of the month following the first date of employment.Flex Plan: Dependent Care RedQuoteFlex Plan: Maximum $5,000 per yearDirect Deposit availableFirst of the month following the first date of employment.AFLACSupplemental insurance - cafeteria planFirst of the month following the first date of employment.Wellness StipendCVCH will reimburse staff up to $30 per month for a local gym membershipORCVCH will reimburse up to $150 per year for a subscription type workout program service (i.e.: Beachbody on Demand, Les Mills, etc.) Immediately. Once employee has submitted invoice to HR/Payroll department.Cell Phone DiscountsDiscounted monthly access feesDiscounted select accessories and special equipmentAvailable for personal cell phones, currently in place with AT&T & VerizonBenefit:Coverage:Effective:Tuition ReimbursementFor approved courses, the cost of tuition, books, and lab fees may be reimbursed at 75% of the actual costs up to a maximum of:• $4,000 for an Associate's degree, vocational, technical, or certification program• $6,000 for a Bachelor's degree• $8,000 for a Master's degreeUpon approval; regular employees who work at least 20 hours per week, have successfully passed their evaluation period and are in good standing may apply.Employees must agree to work for a period of two (2) years from the date of receipt of tuition reimbursement and obtain satisfactory completion of approved courses or Challenge Exams. 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.