QuadMed's dedicated health professionals focus on wellness and prevention, putting the patient at the center. Working as a team, we deliver high quality, integrated care while controlling ever-growing costs. QuadMed is an innovative leader in employer healthcare solutions, one of the fastest growing providers in the country. In partnership with our patients and the companies we serve, our mission is to create a culture of health.
BASIC FUNCTION AND SCOPE
Reporting to the local Clinical Leadership, the Population Health Nurse will have a shared responsibility between Client, Clinic and QuadMed Corporate. This includes the development and monitoring of health improvement activities for positively impacting and improving patient outcomes in the continuum of care.
GENERAL PURPOSE OF JOB
The Population Health Nurse will focus on supporting both the clinical care team and population health services team in improving health outcomes across the population we serve. This position will work closely with the QuadMed health and wellness center providers, medical assistants, and other QuadMed wellness services providers (i.e. CDE, RDN) on a daily basis. S/he will utilize population health management tools, clinical disease guidelines for outreach, identification of care gap analysis in creating work plans for the population health nurse and team to address population health outcomes. This role is responsible for working closely with the Clinic Staff, Clinical Quality, and Operations to enhance clinical quality outcomes on an individual patient level, assist patients throughout the continuum of care and at a population level. This role will have direct accountabilities and collaborative responsibilities to achieved improvement in defined population health metrics. The interactions of this role will encompass both patient and staff contacts.
Assesses client’s overall population for health improvement opportunities to analyze data for trends in health outcomes, gaps in clinical care, and high risk high cost patient conditions (such as hospitalization, ER/UC, prescription medication trends)
Researches best practices and methods along with clinical practice guidelines to improve processes that enhance clinic metrics and health outcomes
Effective use of population health management tool to perform gap analysis on population (i.e. chronic disease, prevention, social factors)
Collaborates with clinical quality to generate meaningful and accurate population health reports, assuring linkage to corporate and client objectives, and performance guarantees
Identifies and interprets data sets from sources such as raw claims files/EMR disease registry/clinic data warehouse
Collaborates with corporate leadership to define the requirements and validate population health data reported at the provider, clinic, programming, and client level
Work plan development and accountability
Creates a strategic outreach program that is customized to their workforce, goals and budget; utilizes data (such as health assessment data, claim/utilization data, employee survey data, and biometric screening results) to provide outreach services
Coordinates and performs regular, proactive outreach to patients according to their work plan
Assists in the development of Quality Improvement studies
Collaboration with patients , providers and health care team
Collaborates with health and wellness center providers to identify high risk/target populations (i.e. high risk diabetics, noncompliant patients)
Collaborates with certified diabetes educator, RDN, Wellness coordinator for targeted outreach
Provides case management services by being a patient advocate, resource and contact person for patients and families assisting the clinical team’s RN in these endeavors
Works as a community partner to improve linkages to outside resources
Assesses, plans, directs and evaluates total nursing care as determined by the patient’s age-related physical, psychosocial, and cultural needs in accordance with established standards, policies and procedures of QuadMed and assigned client groups
Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations
Completes all documentation accurately, timely and efficiently for regulatory compliance; demonstrates skills necessary for proper documentation in the Electronic Medical Record; participate in quality improvement, continuing education, and other patient care programs established by the health center requirements for QuadMed and/or assigned client groups
Scans and imports records, forms, etc. as necessary
May perform occasional clinic nursing duties in the event of an employee illness or absence
Appropriate education and/or experience may be substituted on an equivalent basis
Education: Requires a bachelor’s degree in nursing from an accredited college or university
Five (5) to seven (7) years of experience working in a clinical setting
A minimum of three (3) years of experience in clinical data analysis
A minimum of two (2) years of experience in care coordination, referral coordination, and/or population health management
Chronic Case Management experience preferred
Certificates, Licenses, Registrations:
Requires a current, valid nursing license in the state of the position or compact state license required
Requires current BLS Certification; PALS preferred
Knowledge, Skills & Abilities:
Familiarity working in an electronic medical records system, preferably working with population health management programs, such as disease registries
Must have strong nursing skills, with ability to work collaboratively with members of a clinical team
Exhibit excellent communication (verbally and written) and interpersonal skills, especially working with diverse populations; ability to have crucial conversations with patients one-on-one or in group settings, using a therapeutic and engaging approach to help change behaviors and lifestyles over time.
Ability to manage multiple tasks and organize time efficiently
In conjunction with clinic supervisor, delegate responsibilities to clinic staff (contact patient for follow-up, contact pharmacy to inquire about medication compliance, etc.)
Make recommendations to providers about care plan and promote additional services available to patients
Strong program-planning and marketing skills
Internal Number: 8198 / 8196
QuadMed is a leading provider of onsite, near-site and shared-site employer-sponsored health and wellness centers. We’re a national medical group practice with over 200 providers across the country, yet we still base our health and wellness centers on the values our founder instilled in the company over 25 years ago: to practice health care with a focus on relationships.
We embrace the patient-centered medical home model of care that emphasizes meaningful patient-provider relationships and team collaboration. With a focus on wellness, pre-disease and chronic condition management, QuadMed health and wellness centers promote better living through health education and lifestyle change, with a full scope of care to accommodate referrals.
Some health care professionals call what they do a job. We at QuadMed call it our passion.