Description:

We are currently seeking high energy, engaging nurses with a passion for population health to help transform healthcare in the southeast. As a Population Health Programs Registered Nurse, you will be a key driver of improving health outcomes for our high-risk patient population through timely telephonic outreach to assess and intervene using evidence-based guidelines.

Requirements:

Specifically, you will:

Utilize Lightbeam software to identify high risk, high utilizer patients and document care and interventions in this platform. You will also use Allscripts EHR to document assessments and communicate with the patient’s primary care provider.
Perform telephonic outreach using Ring Central software to assess patients and provide education, resources, and care coordination.
Partner with the providers, pharmacists, and MAs to collaboratively care for your patients
Become an integral part of each partner practice and work collectively with the practices to achieve our population health priorities.
Maintain up-to-date knowledge of regulatory (HEDIS/STARs) standards and guidelines, care management/care coordination practices, social determinants of health assessments, advanced care planning and goals of care discussion and disease management knowledge of high-risk diseases including diabetes, CHF, and COPD.

Requirements

Registered Nurse in the State of Georgia with a minimum of 3 years of care management experience in acute care/post-acute care/ambulatory care settings. Knowledge of discharge planning, post-acute services, DME, social determinants of health and resource coordination is a must.
Ability to maintain a caseload of 250-300 patients monthly.
Effective communication and relationship building skills. Multi-tasking, escalation and delegation skills are crucial to the success of the role.
Interpret data to assess and develop interventions to achieve financial, process and clinical goals to improve outcomes.
Problem-solve with the intent to achieve effective progression of implementing initiatives.
Work with the team to identify and develop recommendations for improvements as needed.
Ability to communicate areas of concern, needed resources, or barriers to achieving goals.
Review and interpret summary data and performance reports for practices and clinicians.
Share best practices within the organization.

Southeast Medical Group

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Population Health Programs Registered Nurse (Remote)