Overview$5,000 Sign on Bonus Available!!! $2,500 Relocation Bonus (greater 50 miles) (external candidates only) The Population Health Nurse will promote effective partnerships between patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines to coordinate care for patients with chronic disease and effectively manages care transitions and facilitate a "shared goal model". He or she will partner with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness. He or she will provide effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk. QualificationsCertifications:Basic Life Support (BLS) within 30 days - American Heart Association (AHA);Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR),Education: College Diploma Nursing, Work Experience: ResponsibilitiesCore Values consistent with patient/family centered approach.Demonstrates professional and effective written and verbal communication skills.Proactively acts as a patient advocate.Recognizes, identifies and responds to opportunities for improvement.Demonstrates effective learning skills based on established, evidence based practice guidelines.Mentoring and coaching of other team members.Cultivates effective partnerships will all members of the patient care team.Delegation of appropriate work and skills in order to optimize and streamline workflows and interoffice resources.Provide a coordinated, strategic approach to identify new or manage an established chronically ill patient population. Stratify patient population according to risk to effectively and efficiently manage patients. Determine frequency of need for provider appointment and CCM encounters. Maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact. Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/timely provider visits, and CCM non-face-to-face monthly encounters. Ensure all required elements are documented for CCM and related AWV component billing. Ensure office staff has an effective internal tracking process to capture results, medication acquisition, missed appointments, and adherence to follow-up appointments. Develop a process to track Annual Wellness Visits (AWV) scheduling and ensure that patient records are reviewed appropriate to identify care gaps prior to visit with the provider visit. Post reminders to secure that all co- morbidities are discussed and documented during AWV. Participate in huddles with provider and care team. Identify scheduling opportunities, determine special needs for patients arriving that office/clinic day, identify patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments needing rescheduling. Ensure sharing of positive patient stories or compliments involving care team efforts. Provide clinical health coaching interventions to motivate patients and families toward successful self-management of chronic disease. Effectively partner with provider practice team members to mobilize needed community resources for the patient and family. In collaboration with the physician or qualified healthcare provider, develop a care plan based on mutual goals with the patient, family, the provider, and emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed. Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider. Attend and participate in all Care Coordination related trainings and meetings as assigned. Participate and monitor PI metrics. About UsFind it here.Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance – and opportunities meet flexibility. Find it all at Carle Health.Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: . Compensation and BenefitsThe compensation range for this position is $30.39per hour - $52.27per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.