Registered Nurse (RN)-Population Health Coordinator
Job Description Job Description Population Health Coordinator-RN FSLA Status: Exempt REPORTS TO: COO Full-Time 40 hours per wk/M-F/ 8a-5p with flexibility Location: Blue Ridge, GA Annual Salary Range: $60,000 - $70,000 Job Summary: The Registered Nurse Population Health Coordinator functions as an integral member of the patient care team and supports the delivery of high-quality, coordinated, patient-centered care. This position combines direct nursing responsibilities with population health management, preventive care, quality improvement, patient outreach, care coordination, and monitoring of quality program measures. The position works collaboratively with providers, clinical staff, leadership, insurance representatives, and other external partners to identify patient needs, close gaps in care, improve health outcomes, and support organizational quality goals. Travel is required to all GMH offices. Company vehicles are provided for site location travel. About GMH: Georgia Mountains Health (GMH) is a non-profit, Federally Qualified Health Center (FQHC), mission driven organization, committed to providing compassionate and quality health care to families in North Georgia (Blue Ridge, Ellijay, Chatsworth and Dahlonega) . We believe in more than just treating patients and we are seeking a mission-oriented candidate who understands the nuances of an FQHC and practice of using UDS measures for quality health care improvement. RESPONSIBILITIES Completes Annual Wellness Visits for qualifying patients, including scheduling, required screenings, medication reconciliation, updating documentation, billing for services, and completing other pertinent information. Uses data analytics, reports, and electronic health record information to identify, monitor, and address population health and insurance quality program measures and gaps in care. Develops and maintains collaborative relationships with insurance companies and other external partners and participates in meetings with insurance representatives to review quality measures, benchmarks, program requirements, and organizational performance. Coordinates and assists with patient outreach initiatives designed to improve preventive care, chronic disease management, quality measures, and completion of identified gaps in care. Provides clinical staff with appropriate educational materials and resources to support patient education, preventive health initiatives, and quality improvement efforts. Monitors quality measure performance, benchmarks, program standings, and potential or actual program payments associated with applicable insurance and quality programs. Reviews Care Plan Reports/DARCI and other available patient information to conduct pre-visit planning, identify gaps in care, determine needed services according to practice protocols, update patient charts with recent test results and correspondence, and obtain necessary medical records or other documentation. Assesses and prioritizes patient needs to ensure timely and appropriate care and provides clinical guidance and support utilizing professional nursing expertise and judgment. Communicates laboratory and diagnostic test results to patients and provides appropriate education, follow-up instructions, and information regarding next steps. Manages prescription refill requests and addresses inquiries from pharmacies regarding prescriptions and medications. Coordinates patient care with disease management, case management, and other appropriate programs and services. Performs chart reviews and extracts necessary clinical information and data for quality reporting, patient outreach, care coordination, and other assigned initiatives. Educates patients and families regarding the importance and benefits of preventive care, recommended screenings, chronic disease management, and completion of applicable quality measures. Encourages and supports the clinical patient care team in implementing preventive health care programs and maintaining a collaborative, team-based approach to health care delivery. Participates in the development, configuration, and improvement of the electronic health record to support clinical workflows, population health management, and clinical decision support, incorporating evidence-based guidelines when appropriate. Reviews EHR documentation for accuracy, completeness, and timely completion in accordance with organizational policies and established workflows. Identifies opportunities to improve clinical workflows, patient outcomes, patient experience, population health processes, and quality performance and provides feedback to the Performance Improvement Committee and/or submits Performance Improvement Forms as appropriate. Maintains confidentiality of patient information in accordance with applicable federal requirements, regulations, and organizational policies. Attends required initial and ongoing training to maintain and enhance knowledge related to the position, including patient safety, patient communication, care coordination, quality improvement, population health, and clinical responsibilities. Travels to Georgia Mountains Health Services locations as necessary to perform assigned responsibilities. Company vehicles are provided for site location travel. Performs other related duties incidental to the work described herein. Performs all nursing duties in accordance with the Georgia Nurse Practice Act and performs all job responsibilities in accordance with the policies and procedures of Georgia Mountains Health Services. EDUCATION, ESSENTIAL SKILLS AND EXPERIENCE Current/Valid Georgia Registered Nurse license. Three or more years of clinical experience preferred, including experience in a primary health care setting. Knowledge of preventive health care, population health, care coordination, and team-based health care delivery. Strong clinical assessment, critical-thinking, and decision-making skills. Ability to use data, reports, and clinical information to identify patient needs and opportunities for quality improvement. Proficiency with electronic health records and other relevant medical software. Proficiency in Microsoft Excel, including the ability to organize, track, analyze, and report data. Strong organizational skills with demonstrated accountability and ability to follow through with assigned and delegated responsibilities. Excellent verbal, written, interpersonal, and presentation skills. Ability to communicate professionally with customer service focus effectively with patients, families, providers, staff, leadership, insurance representatives, and external partners. Ability to function effectively in a collaborative, participatory, team-oriented environment and contribute to the identification and resolution of problems and development of plans, objectives, and strategies. PHYSICAL AND WORK REQUIREMENTS Travel to Georgia Mountains Health Services locations will be required. The position requires sitting or standing for extended periods and working in both office and clinical environments. Must be able to stoop, kneel, bend at the waist, and reach on a daily basis and occasionally lift and move up to 25 pounds. The position requires the ability to work effectively under low to moderate stress and routinely use the telephone, computer keyboard, calculator, and other office equipment. Manual dexterity is required. Hearing and vision must be within or corrected to an appropriate functional range. Learn about Georgia Mountains Health by: Visit our website: www.gamtnhealth.org Visit our Facebook page: https://www.facebook.com/GeorgiaMountainsHealth/ EOE, Drug Free Workplace, eVerify participant. M-F 8a-5p with some flexibility No nights, No weekends, Closed on major holidays
