The Population Health Nurse (PHN) completes the patient comprehensive assessment to manage the healthcare needs of Medicaid patients across the care continuum to optimize individual's health and self-management skills through the multidisciplinary team inclusive of behavioral health and community health workers. Comprehensive assessments will be conducted telephonically or in person at office, public venue or patient home. Patient care plans will be completed by the PHN and the interdisciplinary team in cooperation with the patient to ensure cost effective, quality outcomes focused in the ambulatory setting. The PHN collaborates with other healthcare providers, professionals and community health workers to coordinate care at home.

Schedule

• Monday -Friday
• 8am-4:30pm
• No holidays, no weekends, and no on-call component

Experience

• One year acute nursing care required, hospital based preferred. Experience in home care setting strongly preferred.
• Demonstrated knowledge of the principles and practices of nursing.
• Knowledge of and ability to apply community health principles and practice.
• Demonstrated ability to perform independently as a clinician with minimal supervision or assistance. Experience with self-scheduling of caseload preferred.
• History of flexibility in assuming varied assignments.

Education

• Registered Nurse required.
• Bachelor of Science in Nursing or equivalent required.
• Graduate of a N.L.N. accredited nursing program.

License & Certifications

• RN - License as a professional nurse within MA.
• Active and valid driver's license.

Additional Requirements

• Ability to exercise independent judgement.
• Ability to maintain confidential information.
• Ability to develop and maintain records and communicate clinical data in verbal and written form.
• Willing to be flexible regarding work hours.
• Ability to drive an automobile in inclement weather.
• Conforms with BHS Customer Service and Performance Standards.
• Conforms with Patient's Rights Policy.
• History of dependability in meeting demands of committed work schedule.
• CPR required every two years.
• Data entry skills required.
• Must have proficient computer literacy skills including demonstrated use of Microsoft Office.
• Self-motivated, flexible and ability to initiate change.
• Must be able to perform documentation in real time.
• Must be comfortable engaging with patients via phone, Telehealth and in-person.
• Must be able to demonstrate a positive and can-do attitude.
• Must be able to lead a team, 1 year of leadership experience is preferred.
• Must be comfortable presenting to small groups of patients, providers and peers.
• Must be able to demonstrate positive behavior change within a population.
• Demonstrated ability to handle confidential and sensitive information.
• Strong leadership and interpersonal, oral and written communication and team building skills.