POPULATION HEALTH NURSE

  • Requisition Number: 401407795
  • Department: DIN/Connected Care
  • Location: Durham
  • Type of Position: Regular
  • Shift: First/Day
  • Apply
General Description

The Population Health Nurse is responsible and accountable for clinical expertise for specific complex patient populations.

This role will perform disease management, assessment of disease states and utilization, care plan development and facilitation, referral to appropriate levels of care, etc.

The Population Health Nurse functions as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family and community.

Duties and Responsibilities of this Level

•Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures.

•Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community. Monitor system access to care, services, and treatment including linkage to the medical home.

•Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. •Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process. Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patients understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change. Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.

•Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care, generally from hospital to home or community facilities.

•Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).

•Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.

•Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence based care.

•Facilitate Quality Improvement activities that educate, support, and monitor provider (s), regarding evidence based care for best practice/National Standards of Care (Adapted from CMSA, 2010).

•Utilize innovative nursing and population management tactics to support health throughout the continuum of care in order to promote quality, cost-effective outcome.

•Participate in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research.

•Provide clinical experience in a preceptor role for students attending institutions that have contractual agreements with DUHS. Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff.


The work activity and patient acuity levels can create a stressful atmosphere.

This position may require home visits.