This position will serve as a member of the Value-Based Care (VBC) team at Alo Solutions. The Population Health Nurse will contribute to pursuing transformation in healthcare delivery by administering care management and coordination services to patients as well as closing gaps in care for specific patient populations with a goal of enhancing quality of care and decreasing unnecessary utilization and cost.

This position will work closely with primary care teams with a critical function of helping close gaps in care. Strong communication and interpersonal skills will be needed to engage patients in navigating their journey through the healthcare system and to work with payers and care teams to support care gap closure. Strong clinical expertise and knowledge of value-based care will be needed.

The position reports directly to Associate Director of Population Health. This is a unique and exciting opportunity to join a team that aims to increase quality and decrease cost of care while making a real difference in patients’ lives.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Provides superior customer service to patients by exhibiting respect, empathy, active listening, and clear communication skills through telephonic outreach to patients.
Performs nursing assessments to identify risk factors, level of comfort with self-care and knowledge deficits and creates a patient-centered plan of care, as applicable.
Offers health coaching through relevant communication methods, such as motivational interviewing and teaching, followed by targeted interventions, as appropriate.
Provides disease management by identifying barriers to care through a holistic approach, making appropriate referrals, connecting patients to resources, coordinating health services between different providers, and acting as a patient advocate.
Supports management of many aspects of the patient’s care including follow up to ensure compliance with treatment plan.
Participates in closing gaps in care by educating patients and utilizing standing orders.
Assists patients with more seamless transitions of care from inpatient and emergency department settings back to home or community.
Facilitates and/or completes medication reconciliation and educates patients in regards to their medication regimen.
Collaborates with other members of the care team and VBC team.
Draws relevant patient data from multiple sources, such as electronic medical records, claims data, payer portals, ACO reports and others.
Maintains appropriate clinical documentation of all patient-related activities, including, but not limited to, virtual patient encounters, outreach efforts, and communication events.
Participates in quality validation, and/or process improvement activities.
Demonstrates proficient use of computer software, telephone system and general office equipment.
Performs other duties as assigned.

KNOWLEDGE, SKILLS, ABILITIES AND OTHER QUALIFICATIONS:

Registered nurse (RN) license.
At least 3 years of experience in population health, quality, HEDIS, chronic care management, or a similar environment.
Experience working with electronic medical records.
Excellent verbal, written, and presentation skills.
Excellent PC skills and knowledge of programs such as Microsoft Office.
Demonstrated ability to communicate effectively and professionally, with all levels of management.
Must be able to work independently and demonstrate initiative as well as problem-solving skills within a fast-paced, ever-changing, start-up environment

Alo Solutions provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to religion, race, creed, color, sex, sexual orientation, gender identification, alienage or citizenship status, national origin, age, marital status, pregnancy, disability, veteran or military status, predisposing genetic characteristics or any other characteristic protected by applicable federal, state or local law.

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Population Health Nurse