Population Health Jobs in Delaware (NOW HIRING)

Become part of the Beebe team-an inclusive, missiondriven organization located in a vibrant coastal community. At Beebe, you'll build a rewarding career while making a meaningful impact on the health and wellbeing of our patients. Join a team committed to excellence, collaboration, and compassionate care, and experience the fulfillment that comes from supporting a community that trusts and values the work you do every day. 

Under the supervision of Beebe Healthcare Population Health Care Coordination leadership, the Care Coordination Clinical Nurse II (CC CN II) is a licensed professional Registered Nurse (RN) who provides care coordination services to patients in the home, primary care office, and community settings via face to face, telephonic, or virtual platform (telehealth). Upon successful completion of the required new employee 90-day probationary period onsite at the Population Health Building, the clinical nurse is responsible for assessing, monitoring, and providing ongoing care for patients followed by the Beebe Care Coordination episodic and longitudinal Chronic Care Management (CCM) programs.

This position requires knowledge of clinical nursing, health and wellness coaching, and care coordination. In collaboration with the patient and family as well as the multidisciplinary care team, the CC CN II helps each patient define and achieve their goals of care. As part of episodic or longitudinal CCM, the CC CN II supports the Beebe Medical Group (BMG) primary and specialty care providers and staff through population health management of high and rising risk patients by improving the efficiency, quality, and cost of health care services. In this role, the CC CN II will be expected to collaborate with patients to facilitate healthy behaviors through health coaching to foster healthy diet, exercise, medication, and disease management. The CC CN II helps patients learn strategies and skills designed to stabilize symptoms and disease progression through ongoing support and reinforcement of the plan of care.

This role positively impacts the patient's quality of care and ability to access care and reduces unnecessary costs and capitalizing on revenue generating opportunities. Key functions include building relationships with patients, functioning as a team member in the patient's continuum of care, improving patient experience, mitigating avoidable hospital readmissions, closing care gaps, and identifying social determinant of health barriers that impact the patient's ability to maintain optimal health and wellness. Strong communication and clinical skills are required.

• Assists in the management of patients with chronic diseases following established protocols and systems for disease management in collaboration with providers.
• Promotes positive behavioral changes to facilitate medication compliance and reduction in tertiary care utilization.
• Assist patients with self-management of chronic disease process including patient goal setting, teach-back method of learning, and promotion of patient advocacy that extends into the wider community.
• Assists patients and families with coordination of healthcare services including outside organizations.
• Act as a client advocate partnering with Community Health Workers (CHWs) to provide assistance with social determinant of health (SDoH) needs; initiating referrals to community-based organizations as needed.
• Develop and evaluate a patient plan of care and determine areas of improvement and education.
• Monitors patient's healthcare pathway to ensure adherence, removes obstacles and identifies progress toward desired care outcomes; intervenes to overcome deviations in the expected plan of care; reviews the care plan with patients in conjunction with providers; interacts with the multi-disciplinary care team to negotiate and expedite scheduling and completion of tests, procedures, and consults.
• Collaborates with Care Coordination leadership to participate in and implement process improvement and quality improvement initiatives to maximize patient care outcomes.
• Engages physician and practice team in proactive patient management by addressing medical and behavioral health care needs, follow-up, and referrals.
• Utilizes high risk patient data registries, hospital and payer reports, and other reports to identify and outreach targeted populations benefiting from care coordination programs.
• Offers and coordinates care for complex patients in the practice setting or home as necessary to reinforce disease management education utilizing teach back methods; assist with completion of health care proxy, advanced care planning, or community resource navigation.
• Contributes to comprehensive care plans in collaboration with providers and the multidisciplinary health care team based on evidence-based best practices for chronic illness care.
• Participates in developing patient-centered care plans that address problems /barriers/goals and executes action plans relevant to obstacles in chronic condition management.
• Provides referrals to appropriate community resources and support programs and closes the loop by ensuring that patients can access and follow through on these referrals.
• Collaborates with Population Health Care Coordination leadership to engage and educate providers and teams on newest trends and optimal work patterns to improve the quality of patient care coordination.
• Reviews high-cost patients with the multidisciplinary care team to understand drivers of cost, current treatment plan, future course and prognosis.
• Ensure advance directives and appropriate referrals are addressed such as palliative/hospice and makes recommendations for cost reduction.
• Improves quality by assisting with closing care gaps.
• Reduces healthcare costs by preventing avoidable hospital admissions/readmissions and unnecessary utilization of healthcare resources.
• Assess and address social determinant of health barriers in collaboration with Care Coordination Community Health Workers (CHWs).
• Promotes patient self-management of chronic conditions.
• Identify and submit referrals to address patient behavioral health needs.
• Care coordinate high-risk patients with chronic conditions and high risk stratification scores utilizing payer, claims, PRAPARE tool, demographic, and co-morbidities data including but not limited to COPD, CHF, Diabetes, HTN, and increased acute care and ED utilization.
• Ensure optimized primary care and specialty provider visit scheduling for managing chronic conditions.
• Employee/Team/Provider Engagement.
• Demonstrate effective communication, collaboration, and team-based mentality.
• Demonstrate ability to build relationships with patients.
• Participate in patient huddles/team meetings.
• Maintain patient care standards following established Beebe Healthcare Population Health Care Coordination health education and information guidelines.
• Organize work and utilize time efficiently based on knowledge and procedures.
• Assume responsibility for his/her own professional development and for sharing knowledge with others.
• Responsible for knowledge and compliance with all Beebe Healthcare policies and procedures.
• Maintain professional manner and appearance.
• Other duties as assigned.

• Minimum of two (2) years of work in the healthcare field BLS (CPR & AED) certification issued by the American Heart Association (AHA)
• Previous nursing experience in a Clinic/Outpatient environment
• Previous work using Electronic Health Records (EMR)
• Bilingual English/Spanish language skills are a definite plus
• Proficiency with MS Office Suite (Word, Excel, and Outlook)

• Active RN License - State of Delaware or Compact State 
• BLS - Basic Life Support (AHA) 

• Graduate of an accredited nursing school