REGISTERED NURSE - POPULATION HEALTH- Full Time

Job description

SUMMARY: Coordinate care for the patients of the Population Health Management department and MMC with disease specific plans of care, developed in conjunction with the patient. JOB DUTIES: Ensures timely communication with patients, significant others, and other healthcare providers through professional collaboration. Collaborates with other health care providers to deliver patient-centered care in a manner consistent with safe, efficient and cost-effective resource utilization. Assists with identification and alignment of community resources with patients. Plans integration of care with all appropriate providers. Discusses progress of patients with Pop Health core team. Works collaboratively with the Meadville Medical Center to integrate service delivery system for co-morbidity/co-occurring treatment. Works in collaboration with MMC, subsidiaries, and external collaborating agencies/groups to develop a system of continuity of care. Documentation on chart is timely and appropriate. Assists with community outreach educational programs in correlation with chronic disease management. Provides individual and/or family support. Physical, psychological and emotional outcomes are individu...