Job Description

Job Summary:


- Promotes the mission, vision, and values of Erlanger Health
- Recognizes and responds to opportunities for improvement
- Participation in team huddles
- Uses reporting for monitoring population health and quality programs performance.
- Performs chart reviews to extract data for necessary reporting and gap closure.
- Uses reporting for population health and quality program outreach.
- Provides access to educational materials to non-provider staff.
- Encourages and supports team based, patient centered care including the concepts of preventative care and population health and quality.
- Follows outlined population health and quality workflows and guidelines.
- Actively participates in developing and configuring areas in the EMR to support clinical decision support. Ensures evidence-based guidelines are considered when designing clinical decision support tools.
- Provides input/feedback to Population Health Lead (PHL) to share ideas on improvement of workflow, improvement of patient care experience, and population health and quality programs.
- Assists with assigned outreach programs and activities, as needed.
- Coordinates continuity of patient care with patients and families following hospital admission, discharge, through support of the transitional care management program.
- Improves patient outcomes with chronic disease management; developing processes that support chronic care management and ensuring all requirements have been met for billable reimbursement.
- Provides workflow support for other population health and quality programs, as required.
- Performs other related duties incidental to the work described herein.
- Performs all job duties in accordance with the policies and procedures of Erlanger Health.
- Attends initial training and ongoing trainings assigned to increase knowledge related to job position, patient safety, patient communication, coordinating care for patients, etc.

This position is involved in a team-based approach to care. Team members are trained to meet the highest level of function for their role as per the State of Tennessee/Georgia guidelines. Is trained and assigned (as per their role and responsibilities) to coordinate care for patients and is trained and assigned to support patients/families/caregivers in self-management, self-efficacy and behavior change. Is trained and assigned (as per their role and responsibilities) to manage the practices patient population. Participates in the practice's quality improvement process and performance evaluation.

Education and Experience:

Required:
LPN license with at least two years of clinical experience.

Preferred:
LPN with five or more years of experience in Population Health and Quality programs such as chronic care management, transitional care management, behavioral health and/or quality measure care gaps.

Experience/knowledge of value-based care agreements
Experience/Knowledge of PCMH requirements for certification
Experience/Knowledge of NCQA, CMS, and HEDIS quality requirements
Experience/Knowledge of medical coding

Department Position Summary:
Under the direction of the Manager of Population Health and Quality, the Population Health Nurse functions as an integral member of the patient care team in providing the highest quality of managed care to the patient. The Population Health Nurse will assist in achieving the Triple Aim; of improving Erlanger patient outcomes, reducing cost, and improving patient experience. The Population Health Nurse will be responsible for successfully implementing population health and quality programs and key performance initiatives including but not limited to chronic care management, transitional care management, payer and quality specialist, and care coordination through effective patient outreach. This position may also be responsible for other population health and quality programs or initiatives based on department strategy and goals.
The Population Health Nurse is involved in multiple outreach events throughout the year and acts as an integral part of an interdisciplinary population health team to ensure the Triple Aim of improved outcomes, reduction of cost, and enhanced patient experience.

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