Acute Population Health Nurse

2 meses atrás

Rio Grande do Norte, Brasil FamilyCare Medical Group Tempo inteiro
Why Practice with FamilyCare Medical Group?

FamilyCare Medical Group offers its physicians, clinicians, and support staff a unique and gratifying work environment that combines small-practice amenities and culture - with the reach, resources, and stability of much larger medical organizations. It's an approach that has resulted in a proven and longstanding pattern of growth across the Central New York region. And, in turn, it is an approach that means we're always interested in hearing from talented, passionate, and compassionate doctors and other staff who might join our outstanding team


Position Summary:

This position is directly involved in a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet a patient’s health needs across settings that span the continuum of care (i.e. post hospitalization, skilled nursing, acute rehab and home). Acute care needs are identified through assessment, risk of readmission, data reporting and collaboration with hospital discharge planners, attending and palliative care physicians and advanced practice providers (APPs). The Acute Population Health Nurse supports the team in achieving clinical standards across the continuum of hospital, clinic and community settings, coordinates resources, and provides acute and palliative nursing care.


Essential Job Functions:

Responsibilities include but are not limited to:

  • Develops and updates the individualized care plan based on a comprehensive assessment based upon the patient and/or family/caregiver and the patient’s primary care provider.
  • Engages community resources that are timely and cost-effective to obtain optimum value for the patient in support of medical and social determinants of health.
  • Provides education/coaching in self-management of disease processes.
  • Monitors the patient’s medication adherence in conjunction with the Family Care Medical Group Pharmacist.
  • Conducts ongoing communication and collaboration with the patient and/or family/caregiver, as well as the patient’s PCP and other significant health care providers.
  • Conducts, at a minimum, monthly monitoring of the patient’s health, safety, and functional status, and progress toward established goals.
  • Conducts in-home visits to palliative care patients on an as-needed basis (20% of the position).
Required Qualifications:
  • Registered Nurse (RN) with active New York State License – BSN preferred but experience considered in lieu of.
  • 5 years minimum in nursing with 3 years case management preferred.
  • Experience with geriatric population preferred.
  • Must demonstrate strong verbal and written communication skills.
  • Must demonstrate ability to work as part of the team.

To apply, email a cover note and resume to:

Why choose FCMG? At FamilyCare Medical Group, we strive for excellence. Our commitment to hiring top-quality talent and creating a positive work environment is what sets us apart from other organizations. We work hard to develop an atmosphere that makes employees feel welcomed, valued, appreciated, and recognized for their contributions. Our goal is to retain skilled, dedicated professionals who are passionate about our company’s mission; with competitive salaries, insurance, and additional benefits making FamilyCare Medical Group an easy choice for potential applicants.#J-18808-Ljbffr

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