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If you have a passion applying the nursing process and helping others, this is the role for you. The Population Health Nurse is an essential member of a team responsible for the assessment, education, and care management of populations. Responsibilities include performing and documenting patient visits and monitoring conditions, conducting tests, and reporting information back to the primary care provider. The Population Health nurse communicates with patients and/or guardians to update on results, medications and treatment plans, and communicates further care options and support. The Population Health Nurse provides nursing expertise and is the liaison between the clinical care teams and the Population Health Team.

• Utilize team-based care approach to develop and oversee patient care management strategies
• Complete patient blood pressure, glucose, and vitals testing as needed, and communicate further care options
• Learn and apply clinic policies and procedures for high-quality patient care and engagement outreach
• Protect patient information and maintain confidentiality according to HIPAA guidelines
• Monitor for signs of chronic disease complications and need for preventive care
• Evaluate patient's compliance with plan of care and regularly communicate updates to provider(s)
• Listen to and answer patient and/or family concerns and foster referrals when needed
• Implement best practices for patient care gap closures, social determinants of health screenings, disease- specific patient education, chronic care management, and clinical quality improvements.
• Provide suggestions for improved healthcare options to providers, family, and patients
• Document activities accurately and timely in the electronic health record
• Attend professional development meetings and trainings
• Participate in clinic, quality and Population Health Team meetings
• Implement new programs based on community health needs and strategic planning discussions
• Assist selection of culturally appropriate educational materials for populations experiencing health disparities
• Provide medical expertise and technical assistance to Population Health and Quality teams
• Collect data and/or report on activities that demonstrate progress toward team objectives
• Assist the clinical and quality teams, as needed, with special projects
• Collaborate with Population Health and Quality teams to develop patient and staff success stories
• Provide chronic disease management education and consultation at community events

Carries out Vibrant Health's mission to provide access to respectful, empowering, culturally sensitive and appropriate high-quality health care for the community, regardless of socio-economic obstacles.

Uses supervision and consultation to maximize available resources in the completion of work duties.

All job responsibilities will be carried out under the direction of the organization's policies and procedures.

Additional responsibilities may be assigned as needed to maintain and improve effective functioning of the department and to advance the mission of the organization.

At Vibrant Health, we understand that many, if not most, people have experienced trauma in their lives. We have made a commitment to trauma informed care and support and educate team members continued development of understanding of how trauma affects individuals and coping strategies. We expect employees to incorporate their understanding about trauma into interactions with our patients and families, clinic visitors, and with each other.

LPN, RN, or Associate's degree or higher and relevant Kansas license and certification

BLS for Health Care Providers

Expertise in chronic disease prevention and management Ability to execute work within parameters set by a work plan

Skill or willingness to learn use of personal computers, Microsoft Office, and electronic health record

Individual must:

1. Assess patient health problems and needs according to the latest nursing standards, develop and
2. implement nursing care plans, and maintain accurate and complete medical records
3. Develop rapport with patients and their families, community and other health care personnel.
4. Exhibit a professional and respectful demeanor.
5. Be comfortable speaking with patients in-person, over-the-phone, and/or virtually
6. Work successfully independently and within a team
7. Demonstrate excellent customer service, helpfulness, and a positive attitude.
8. Possess superior organizational skills, attention to detail and the ability to multi-task and meet deadlines.
9. Demonstrate the ability to recognize, understand, and appreciate the value of cultural diversity and communicate medical information in plain language.
10. Demonstrate social and cultural sensitivity to ethnically and economically diverse patients and staff.
11. Exhibit experience and working knowledge of local community resources
12. Hold current drivers' license and acceptable driving record and reliable transportation.
13. Travel to all parts of the facility and network of Wyandotte County clinic locations
14. Possess current CPR certification, which can be provided through Vibrant Health if needed.
15. Proficiency in use of personal computers and Microsoft Office (Outlook, Word and Excel).

Experience working in community-based or populations-based clinics and lived experience or close connection to the community being served

Working knowledge of electronic health records, medical terminology, and third-party health care coverage Diabetic Education Certification

Oral and written fluency in Spanish or a language other than English highly preferred.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands and fingers to handle or feel objects, tools or controls; reach with hands and arms; climb stairs; talk and hear. The employee must frequently lift and/or move materials that may weigh up to 40 pounds.

Work Environment

Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must have manual dexterity and experience to perform handwritten paper work, recordkeeping, and filing.

• Prolonged sitting, standing, or walking may be required.

• Frequent bending/stooping, squatting, reaching above the shoulders, twisting and turning, kneeling, and pushing/pulling may be required.
• Employment is contingent upon successful clearance from Criminal, Kansas and Missouri Child/Elder Abuse and Neglect, Sex Offender background investigations, TB testing, pre- employment drug testing, and verification of Hepatitis-B, flu and COVID-19 immunizations.

• Occasional evening and weekend availability are required.

Commitment to Diversity

We are proud to be an Equal Employment Opportunity (EEO) and Vietnam Era Veterans Readjustment Assistance Act (VEVRAA) Employer. We are committed to cultivating a workplace in which diverse perspectives and experiences are welcomed and respected. We do not discriminate on the basis of race, color, religion, creed, ancestry, national origin, sex, age, disability (physical or mental), marital or veteran status, genetic information, sexual orientation, gender identity, political ideology, or membership in any other legally protected class. We are an Affirmative Action employer. We encourage individuals with diverse backgrounds to apply and desire priority referrals of protected veterans.