Employment Type:

Full time

Shift:

Description:

GENERAL SUMMARY AND PURPOSE:

Under supervision of clinical leadership from Holy Cross Physician Partners, the Population Health Registered Nurse (PHRN) Team Lead provides care management and coordination for members attributed to specially defined populations. Additionally, the PHRN Team Lead will act as the primary resource for the PHRNs, guiding workflow decisions, as well as providing oversight of daily staffing needs and quality assurance. The Lead will attend management meetings and work on effective and efficient processes, workflows, and training of staff to enhance the level of care management provided to our patients.

The goals of the PHRN are to coordinate and manage care to meet the multiple needs of members with high and rising risks, ensure continuity, and decrease fragmentation of care and services. The PHRN assists the member in achieving their highest level of wellness, provides coaching for self-management in both recovery and learning to live with chronic illness, and acts as an advocate. Care management may be a continuous or intermittent process; the PHRN assesses needs, develops individualized care plans, coordinates services, collaborates with interprofessional members of the care team, facilitates access to resources, monitors and evaluates outcomes, and documents such interventions appropriately within the legal medical record.

ESSENTIAL FUNCTIONS A N D RE SP O NS I B ILI T IE S

*Primary resource for the care management team including PHRNs and *Population Health Care Coordination Assistants to guide decisions on care and workflow

*Ensures optimal daily staffing coverage for planned PTO and unplanned PTO needs

*Work collaboratively with management on quality assurance program to ensure optimal documentation and patient management

*Participates in designated quality initiatives, program development and management, and committees at the direction of the Holy cross Physician Partners leadership team

*Subject matter expert regarding ACO health plans and resources available to patients through their respective plan

*Collaborates with appropriate providers, facilities, external healthcare organizations throughout the continuum of care and communicates with an interdisciplinary team to develop and maintain positive working relationships while providing for the diverse needs of members and families.

*Functions as a coordinator and manager of a defined health population, with modifiable risks, across multiple care settings and for multiple physicians/health care providers or health plan counterparts.

*Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources.

*Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are member-centric, promoting quality and efficiency in the delivery of health care.

• Serves in an expanded healthcare role to collaborate with all interprofessional colleagues, and members /families to ensure the delivery of quality, efficient, and cost-effective health care services.

SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE :

• BSN required; Master's degree in nursing preferred.

• 5+ years' experience in a healthcare environment. Experience with adult medicine in primary care/ambulatory care, ED, critical care, or hospital medical-surgical setting, including health plans or post-acute care such as home health agency. Care/Case management experience preferred.

• Respects diverse opinions, values, and religious and cultural ideals

• Demonstrates ability to work autonomously and practice effectively in a fluid, dynamic, and rapidly changing environment.

• Displays influential leadership qualities including effective time management, communication skills (verbal, written listening), problem solving, critical thinking, priority setting, and delegation.

• Exhibits an outcome and continuous quality improvement focus with the ability to interpret and synthesize data.

• Develops positive, longitudinal relationships and sets appropriate boundaries with members/families.

• Displays excellent assessment and triage skills. Ability to integrate evidence into clinical practice.

• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.

• Demonstrates proficiency in use of computer and other applicable technology.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran