Population Health Nurse; PHN - Duke Primary Care Pickett Road

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

Pursue your passion for caring with Duke Primary Care, which offers family, adolescent, and internal medicine services as well as urgent, general pediatric, and virtual care at nearly 50 clinic locations across central North Carolina.

• Duke University Health System is designated as a Magnet organization
• Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
• Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
• Duke University Health System has 6000+ registered nurses
• Quality of Life:
  Living in the Triangle!
• Relocation Assistance (based on eligibility)

Population Health Nurse - Duke Primary Care Pickett Road

Duke Primary Care Pickett Road is a patient-centered primary care clinic providing comprehensive healthcare services to individuals and families in the Durham, NC, area. Serving a diverse patient population, including adults, seniors, and adolescents, the clinic offers a wide range of services, including preventive care, chronic disease management, acute illness treatment, women's health, and on-site diagnostic testing. As part of the Duke Health network, the clinic is committed to delivering high-quality, evidence-based medical care with a focus on patient-centered treatment, health education, and seamless coordination with Duke Health specialists when advanced care is needed.

Location:

3004 Tower Boulevard, Durham, NC 27707

Hours:

8 am – 5 pm Monday – Friday

The Population Health Nurse partners with pediatric patients with complex health needs, delivering care and education through a dynamic blend of educational telehealth visits and care coordination. This role guides children and their families in managing chronic illnesses, develops and coordinates individualized care plans, and ensures connection to the right resources and support. As an integral member of an interdisciplinary team, the nurse helps families navigate care transitions, empowers them with knowledge and tools, and drives improved, patient-centered health outcomes.

• Deliver specialized nursing care, create individualized care plans, and educate patients and families while using clinical judgment and following established policies.
• Identify the educational needs of patients and caregivers related to their condition, recovery, and transition back to home and community life.
• Ensure patients have access to the right care, services, and resources, including coordination with their medical home.
• Address the whole person — medical, emotional, behavioral, psychosocial, and spiritual needs — for truly comprehensive care.
• Actively involve patients and their support systems in decision-making, using a collaborative approach to build self‑management skills and encourage long‑term healthy behaviors.
• Communicate and coordinate with providers and care team members to reduce gaps in care, especially during transitions like hospital‑to‑home.
• Set measurable goals for patients and monitor the quality and success of interventions over time.
• Use data from medical records, claims, and program reports to identify patients who need outreach, education, and additional support.
• Advocate for patients and work closely with providers to ensure care is evidence-based and aligned with national standards.
• Support quality improvement initiatives by educating providers, tracking outcomes, and helping implement best practices.
• Apply innovative population health strategies to improve health outcomes and keep care cost-effective.
• Participate in performance improvement projects, product evaluations, and clinical research to advance patient care.
• Serve as a preceptor and mentor for nursing students and new staff, providing guidance and coaching in both formal and informal settings.
• May perform…