Population Health Programs Registered Nurse

Join our dynamic team at Southeast Primary Care Partners! We are on the lookout for high-energy, engaging nurses with a zeal for Population Health. This role is pivotal in transforming healthcare in the southeast by improving health outcomes for our high-risk patient population. The position involves extensive telephonic outreach, employing evidence-based guidelines to assess and intervene.

Key Responsibilities:

• Utilize software for identifying high-risk patients and documenting care and interventions. Also, employ Allscripts 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.

Physical & Mental Requirements:

• Ability to sit or stand for extended periods.
• Fine motor skills for operating office equipment/machinery.
• Comprehension of verbal/written instructions.
• Logical reasoning for problem-solving.
• Occasional travel to support business needs.

Join us in our mission to revolutionize healthcare in the southeast. Apply now to become a part of this exciting journey!