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ABOUT THE ORGANIZATION
Community Health Programs is a network of health centers and caring professionals that provide outstanding primary and preventive care for patients of all ages. What's truly unique to CHP is our broad spectrum of support services that extend beyond medical and dental issues to strengthen families and improve children's well-being. The region is a federally designated rural community and a Medically Underserved Population Area.
Community Health Programs embraces its role as a nonprofit health care provider and community partner. We are a leader in the communities we serve by providing high quality healthcare, dental services, wellness education and family support services. CHP outreach provides free health screenings, insurance enrollment assistance as well as information so people can learn how to take better care of themselves and their families.
Salary: $70,000 - $90,000 / Annually Summary: The ACO Pediatric Population Health Nurse (PPHN) completes the patient comprehensive assessment to manage the healthcare needs of 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 an office, public venue, or patient home. Patient care plans will be completed by the PPHN and the interdisciplinary team in cooperation with the patient to ensure cost effective, quality outcomes focused on the ambulatory setting. The PPHN collaborates with other healthcare providers, professionals, and community health workers to coordinate care at home. This person will support CHP's mission, vision, and values and will adhere to compliance protocols as well as CHP's policies and procedures. ACO Pediatric Population Health Nurse Essential Duties and Responsibilities: Provides open communication to entire team facilitating engagement and teamwork. Assists in defining standards of excellence for patient care planning, working directly with high-risk members with complex conditions and develops and implements an individual, coordinated care plan, in collaboration with the member, multidisciplinary team, primary care physician and/or specialist, as well as community resources. Care plans with defined, actionable, measurable and time sensitive goals and objectives and progress against the plan are documented in a Fallon or CHP care management system. Performs medication reconciliation during initial and follow-up assessments as needed. Demonstrates knowledge and compliance with Fallon and CHP policies and procedures including but not limited to: Medicaid Conditions of Participation. Performs assessment/data collection in an ongoing and systematic manner, focusing on physiological, psychological, and cognitive findings. Identifies actual and potential healthcare problems based on physiological, psychological, and cognitive findings. Develops a standard-based plan of care setting outcome goals. Incorporates principles of rehabilitation, nutrition, safety, education, etc. Coordinates standard-based plan of care (POC) with client/significant other (SO) and appropriate members of the healthcare team. Implements care according to established standards and physician orders. Evaluates and revises Plan of Care based on client progress toward desired outcomes. Revises POC based on evaluation of outcomes. Client/SO teaching: Demonstrates ability to identify, plan and implement education program evidenced by documented initiation of teaching protocols, Disease Management protocols, instruction sheets and/or discharge plan instructions. Demonstrates technical proficiency as evidenced by completion of skills checklist during orientation, home visit supervision by clinical nursing manager and annual agency competency assessment. Completes all clinical documentation in a timely manner according to regulation and agency policy. Documentation reflects client problems, care given, response and outcomes. Promotes family/caregiver acceptance of responsibility for providing care. Demonstrates ability to supervise HHA in accordance with agency policy and CMS regulations. Delegates appropriate responsibility to HHA or other team members (LPN) based on care needs, staff knowledge and job description. Advocates for the needs of individuals in the community and assists in their effective use of resources for diagnosis, treatment, and rehabilitation. Organizes and coordinates delivery of client care in a safe, efficient, and cost-effective manner: Completes assigned visits and communicates laptop information according to Fallon and CHP Policy. Maintains agency-set accountability for productivity. Utilizes office time to complete necessary documentation, follow-up with physician and community resources. Keeps schedule accurate and up to date. Works scheduled shift/hours. Demonstrates flexibility in adapting to changing client and agency needs. assumes additional responsibilities when necessary. Participates in attainment of agency goals for outcome scores and Patient Satisfaction scores. Gives report to manager and team members as requested. Attends team/staff meetings as scheduled. Provides proper notification of absences. Addresses professional education needs through continuing education, journals and/or formal collegiate education. Takes action to achieve goals formulated in annual evaluation. Practices effective problem-solving, identification and resolution skills, utilizes appropriate resources for support. Identifies self-strengths and weaknesses, seeks guidance in areas of question. Competencies: To perform the job successfully, an individual should demonstrate the following competencies: 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 Patient's Rights Policy. History of dependability in meeting demands of committed work schedule. 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. 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. Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Experience: One-year acute nursing care required; hospital based preferred. Experience in home care setting strongly preferred. One-year of leadership experience. 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 flexibilit
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