Population Health (USRN - NY)

The Population Health Support Nurse (USRN - NY) is responsible for monitoring and improving health outcomes for defined patient populations by integrating clinical expertise with health principles aimed at reducing the need for acute healthcare. The nurse will focus on disease management, preventative care, care coordination, and addressing social determinants of health. The nurse will work collaboratively with interdisciplinary teams to ensure seamless transitions of care and promote patient self-management.

• →Conducts telephonic visits with clients to complete assessments, review recent hospital or ER visits, provide disease management education, and address flagged client needs.
• →Responsible for meeting productivity standards set by the organization.
• →Works with other members of the team to meet KPI’s and program targets.
• →Utilizes critical thinking skills to ensure client needs are prioritized.
• →Support program enrollment and monitor participation.
• →Support clients who are post-discharge from hospitalization, emergency department, or skilled nursing facilities.
• →Communicate findings as needed to the clients’ primary care physician and/or specialists.
• →Document communication with clients, caregivers, and providers timely and accurately.
• →Connect clients to care and support: (Not limited to):
  • →Behavioral Health
  • →Condition Management to Benefits Engagement
  • →Provider Referrals
• →Educate client, caregiver, and family as appropriate and provide information on available community resources.
• →Review client needs/referrals as identified by caregivers and others - ensure appropriate follow-up occurs.
• →Seek clarification from caregiver and client as needed to formulate clinical judgement for next best actions.
• →Document accordingly in the EHR and other software no later than 24 hours after client contact.

• Experience working with at-risk and elderly populations.
• Ability to work independently and as part of a broader care team.
• Demonstrate flexibility and adaptability in managing changing priorities and patient needs.
• Ability to foster a positive work environment and collaborate effectively with team members.
• Proactive in resolving problems.
• Proficient with Microsoft Office Suite.
• Strong problem-solving skills.
• Ability to leverage community resources to benefit clients.

• US Registered Nurse - NY License
• Three (3)+ years of experience working in hospital or home care preferred
• Strong preference for experience with elder population in a home health care, hospice/palliative or facility setting.

Industry standards applicable to the state depending on work experience and level of expertise.

US Eastern Standard Time (EST) - 9am to 6pm

We embrace the flexibility and convenience of a remote working environment, and you will collaborate with an international team while contributing to our growing business, all from the comfort of your home.

You will need to have some essential tools – a reliable computer and noise-cancelling headset, a second monitor for enhanced productivity, and a stable internet connection. You’ll also be required to have a backup internet connection, ensuring that you’re well-equipped to complete your work seamlessly.