Population Health Nurse Coordinator

The Visiting Nurse Association of Greater Philadelphia is a leading provider of home health, hospice, and palliative care services in Philadelphia and designated areas of Bucks, Delaware, and Montgomery counties. The VNA offers a variety of clinical services and is proud of its home health 4.0 star quality rating and free-standing hospice inpatient unit. Since 1886, the VNA of Greater Philadelphia has remained true to its commitment to help patients remain safe and comfortable at home.
Population Health Nurse Coordinator
The VNA has launched a population health program and is seeking a Population Health Nurse Coordinator. This is an exciting opportunity for a registered nurse with 2-3 prior experience in caring for patients with chronic diseases. You will provide clinical interventions to identify and address signs and symptoms of disease exacerbation while promoting patient engagement to support adherence to program protocols and the prescribed treatment regimen. This role includes occasional, urgent home visits to address complications of disease exacerbation. If you enjoy providing patient education, health coaching, and health promotion, we strongly encourage you to apply for this position.
Position Summary: The Population Health Nurse Coordinator is responsible for monitoring and care coordination for Remote Patient Monitoring (RPM) program patients. The nurse coordinator collaborates with the patient’s physician/healthcare provider and members of the RPM care team with a goal of reducing the incidence of emergent care and unplanned and hospital admissions.
Essential Functions:

• Makes urgent home visits to program patients to provide clinical interventions and address signs and symptoms of disease exacerbation.
• Collaborates with patients, caregivers, the patient’s physician, and other members of the health care team to promote optimal health outcomes for program participants.
• Health Promotion
• Motivational Interviewing
• Demonstrates competency in chronic care professional evidence-based clinical standards including:
• Health Coaching

Other Duties:

• Assesses/reassesses patient appropriateness for the RPM program.
• Complies with Agency Personnel Policies and Procedures.
• Provides daily monitoring of RPM program patients and adheres to program clinical protocols.
• Ensures timely set up of RPM system in patient’s home.
• Participates in care management conferences and required RPM meetings with vendor and staff.
• Maintains clinical skills, professional nursing competency and knowledge of population health principles.
• Notifies the patient’s physician of signs and symptoms of disease exacerbation or other change in health status.
• Supports the mission values and vision of the VNAGP.
• Provides supervision and guidance for program’s Community Health Workers and RPM technician.
• Provides patient/caregiver education to promote disease self-management skills.
• Ensures distribution of patient biometric data to healthcare providers biweekly and upon request.
• Promotes patient/caregiver engagement to ensure patient participation in RPM and adherence to the individual patient treatment plan.
• Responsible for meeting quantitative and qualitative program performance metrics.
• Responds to patient data alerts and takes prompt action to initiate clinical interventions to address abnormal monitoring results.
• Establishes and maintains effective working relationships with staff, peers, other agency departments and external customers.
• Demonstrates cultural competency while working with diverse client population.
• Provides excellent customer service.
• Disseminates data including, but not limited to, program volume and other assigned metrics to Agency leadership.
• Resolves difficult situations and provides a high level of service to program participants.
• Other duties as requested.
• Assists patient/caregiver in setting and attaining health-related goals utilizing evidence based clinical practices including motivational interviewing, health coaching, and health promotion.
• Assumes responsibility for professional growth and continuing education.
• Obtains physician/healthcare provider orders for RPM.
• Assigns Community Health Worker, as needed, to enhance patient engagement, improve access to primary care provider, improve health literacy, connect patients to community resources, and support attainment of individual patient and program goals.

Knowledge and Experience:

• Current PA nursing license.
• Empathy and compassion towards chronically ill patients and their families.
• RN with minimum 2-3 years prior chronic care experience.
• Outstanding interpersonal skills with excellent verbal and written communication skills, including effective listening skills.
• Solid critical thinking skills and attentive to details.
• Proficient in the use of electronic documentation, EMR use, and data management.
• Self-motivated and ability to work with little supervision.
• Strong organizational skills required.
• Punctual and reliable team member with a positive attitude and superior customer service skills.

Education:

• Graduate of an accredited school of nursing with a nursing diploma or associates degree. BSN strongly preferred.
• Related American Nurses Credentialing Center certification, preferred.

#vnaphilly1