Population Health Nurse - RN (Remote; Oregon-Only)

Thank you for your interest in career opportunities at Central City Concern! Since 1979, the Portland Community has trusted Central City Concern (CCC) to help people create meaningful, long-term change. Every year, we serve more than 13,000 people experiencing, or at risk-of, homelessness with affordable and supportive housing, person-centered health care, addiction recovery and employment assistance. By providing health care, housing and jobs, CCC is ending homelessness in Portland and helping people achieve their highest potential.

Now Hiring: Join Central City Concern as our Population Health Nurse! Location: Remote (Note: Candidates must be Oregon-based) Schedule: Full-Time (Monday-Friday; 8:00am-4:30pm) Compensation: $44 - $57/hour (depending on years of experience as a licensed RN + internal equity) ROLE SUMMARY: The Population Health Nurse provides comprehensive community health services directed towards the prevention of disease, the promotion of health, and the client’s self-care using professional judgment in comprehensive assessment, screening, nursing diagnosis, care planning, health information /education, referral, and evaluation. The Population Health Nurse supports primary care in providing assessment and outreach to promote continuity of care and health promotion across multiple clinic sites.

Client Care: Supports Primary Care Team in following up on clients who are currently admitted or recently discharged from the hospital or Emergency Department, assessing client needs for follow up, providing education and connecting them to other services. Perform telephone outreach to clients, other CCC service providers, and patient-identified supports to facilitate non-coercive care gap outreach to patients. Outreach is based on population health indicators to improve the health of the client and to prepare CCC for a value-based payment Care gaps include but are not limited to: Completion of routine preventive services; Follow up for chronic disease management; Follow up after hospitalization; Re-engagement of patients who have not had a recent appointment; and Engagement of attributed patients who have yet established care. Perform telephone triage as Provides instruction, training, and health information on self-care and health maintenance as per the clients care plan. Adhere to all state and federal privacy regulations, including HIPAA and 42 CFR Part 2, and to CCC policies and agreements regarding confidentiality, privacy, and security. Support compliance with all privacy and security requirements pursuant to community partners’ and outside providers’ patient confidentiality agreements, including privacy and security requirements for EMR access. This includes immediately reporting any breach of protected health information or personal identification information of any person receiving CCC services by CCC or an outside provider to the CCC Compliance Department, as well as to your supervisor or their designee. Directs and assigns the care of individuals & groups of clients to members of the team based on the scope of practice and clinical skills needed by the clients. Assures client follow-up as needed for abnormal labs, specialty/referral reports, clinical treatment and prescriptions, etc.