Population Health Programs, RN

About the role

Join our dynamic team at Southeast Primary Care Partners! We are seeking high-energy, engaging nurses passionate about population health. This role plays a key part in transforming healthcare in the southeast by improving health outcomes for our high-risk patient population through extensive telephonic outreach and evidence-based interventions.

Responsibilities

• Utilize software for identifying high-risk patients and documenting care and interventions, including 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.
• Manage a caseload of 250-300 patients monthly.

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.
• Experience in Electronic Health Record (EHR) documentation, preferably Allscripts/Veradigm.
• Bachelor’s degree in Nursing.
• Excellent communication, multitasking, escalation, and delegation skills.
• Proficiency in data interpretation, problem-solving, and implementing initiatives.
• Collaborative approach to identify and recommend improvements.

Physical and Mental Requirements

• Ability to lift up to 50 pounds.
• Ability to push or pull heavy objects using up to 50 pounds of force.
• Ability to sit or stand for extended periods of time.
• Ability to use fine motor skills to operate office equipment and/or machinery.
• Ability to receive and comprehend instructions verbally and/or in writing.
• Ability to use logical reasoning for simple and complex problem solving.
• Ability to travel to multiple locations to support business needs as required.

FLSA Classification: Exempt