Population Health Nurse

Community Health Center, Inc. (CHC) is one of the country’s most creative and dynamic providers of primary medical, dental, and behavioral health services, and a leader in practice-based research, health professionals training, and use of innovative technologies to advance health and healthcare. CHC is designated as a federally qualified health center and a patient-centered medical home by HRSA, the Joint Commission, and NCQA, respectively. We deliver more than 500,000 patient visits per year from primary care hubs and community clinics across the state of CT, all connected by technology and common standards for quality. We employ several hundred medical, dental, and behavioral health providers who are engaged in practice, teaching, and research. Our Weitzman Institute is devoted to research and practice transformation and is recognized around the country as one of the premier research institutes focused on improving health care and health outcomes for special and vulnerable populations. In addition, the organization has developed three wholly owned subsidiaries from the original pilot developments within the Weitzman Institute: the National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC), the National Institute for Medical Assistant Advancement and ConferMed.

The Population Health Nurse provides high quality comprehensive, professional nursing care to individuals throughout the lifespan. The PHN provides patients with both general and focused health education regarding preventive, chronic and episodic health care issues.

Outreach to patients to provide health care education during patient visits, by video and by telephone. Follows up on emergency room visits and hospital discharges. Accurately documents all aspects of patient care in the medical chart on a timely basis. Completes medication reconciliation processes Retrieves hospital discharge summaries from the appropriate portal and uploads into patient records, as needed Addresses care gaps related to value based metrics as assigned Other work as delegated by the Population Health Department Director or Supervisor Additional Activities and Responsibilities: Participates in quality improvement projects. Precepts others Participates in on going nursing education activities. Communicates client information to providers and the clinical team accurately. Accurately takes messages, and communicates on the telephone. Communicates effectively with other administrative staff, collaborates with medical providers, nursing staff and members of leadership. Access to clients’ charts and health care information within appropriate parameters. Maintains client confidentiality. Possess desire to collaborate with a team in a positive manner, providing insightful and evidence–based information This Position is available for remote work.