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RN - ACO / Population Health
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Full-time
- This position will work at the Mahomet, Rantoul, and Monticello Family Practice Locations The Population Health Nurse will promote effective partnerships between patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines to coordinate care for patients with chronic disease and effectively manages care transitions and facilitate a "shared goal model".
- He or she will provide effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk.
- Determine frequency of need for provider appointment and CCM encounters.
- Maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
- Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/timely provider visits, and CCM non-face-to-face monthly encounters.
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