Population Health Nurse - Timberlyne Family Medicine
Duke University Health System
Application
Details
Posted: 18-Jan-25
Location: Chapel Hill, North Carolina
Internal Number: 253570
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
About Duke Primary Care
Pursue your passion for caring with Duke Primary Care, which offers family, adolescent, and internal medicine services as well as urgent, general pediatric, and virtual care at nearly 50 clinic locations across central North Carolina.
Population Health Nurse - Duke Primary Care Timberlyne
The Population Health Nurse plays a transformative role in geriatric care, championing prevention, personalized coordination, and patient empowerment. With a focus on comprehensive assessments and tailored care plans, they ensure seamless transitions and deliver exceptional outcomes. By educating patients, streamlining care, and advocating for evidence-based treatments, these nurses become trusted partners in each patient's healthcare journey. In a collaborative environment, they inspire change, mentor peers, and drive innovation, making a lasting impact on individuals and fostering healthier, thriving communities.
Location: This position is split between two locations: Timberlyne Family Medicine (4 days per week): 77 Vilcom Center Drive: Suite 200, Chapel Hill NC 27514
As well as Galloway Ridge Primary Care (1 day per week): 50 Craggenmore Drive, Pittsboro NC, 27312
Hours: 8am - 5pm Monday to Friday
What you will do:
The Population Health Nurse is responsible and accountable for clinical expertise for specific complex patient populations.
Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures.
Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community.
Monitor system access to care, services, and treatment including linkage to the medical home.
Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care generally from hospital to home or community facilities.
Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.
Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence-based care.
Facilitate Quality Improvement activities that educate, support, and monitor provider(s), regarding evidence-based care for best practice/National Standards of Care (Adapted from CMSA, 2010).
Utilize innovative nursing and population management tactics to support health throughout the continuum of care to promote quality, cost-effective outcomes.
Participate in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research.
Provide clinical experience in a preceptor role for students attending institutions that have contractual agreements with DUHS. Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff.
This position may require home visits however; position specific details and duties are available upon request.
The work activity and patient acuity levels can create a stressful atmosphere.
What you will need:
Education
BSN
Experience
3 years of nursing experience required
Degrees, Licensure, and/or Certification
Current RN licensure in the state of North Carolina required.
Knowledge, Skills, and Abilities
The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are:
Organized and motivated by a fast-paced environment
Able to manage multiple tasks/projects simultaneously
Proficient in review and assess needs quickly
Strong with the use of computer software tools and data files
Comfortable with continuous change and self-initiating
Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics)
Distinguishing Characteristics of this Level
Additional job expectations include the ability to: -- Maintain strict confidentiality
Promote programs and services to community
Build effective and trusting relationships with patient/peers
Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests
Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions
Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate
Use data to analyze trends and to verify data
Self-directed and able to organize and manage multiple tasks/projects simultaneously
Ability to promote programs and services to community
Proficient in review of medical records and other patient care information
Job Title: POPULATION HEALTH NURSE Job Code: 5555 FLSA: E Job Level: G1 Revised Date: 05/01/2024 Supervisory Responsibility: No
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.
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Important Information for CPHQ Recertification
The recertification process has been streamlined. Unlike previous years, you don’t need to list out your CE activities at the time of completing your application. Instead, you will be asked to attest to having met the requirements, further aligning with the honor-based system of recertification. In the event that your application is randomly selected for audit, you may be required to list your CE activities and submit supporting documentation.
While you may participate in NAHQ learning opportunities (Learning Labs, JHQ articles, etc.), you can only claim CE credit once for each activity. Therefore, if you’ve previously earned CE from a NAHQ learning opportunity, you can’t claim it again, nor will you see the repeat CE appear in your “My Learning� tab. This includes activities used in previous recertification cycles.
Remember, if you’re recertifying during the grace period (1/1/24-1/31/24), you already had to earn your CE hours by Dec 31, 2023.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ’s twice-validated healthcare quality competency framework.
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Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
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Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
Member Briefing Workshop and Healthcare Quality Week Webinar
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You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ's twice-validated healthcare quality competency framework.