Registered Nurse,RN - Population Health Nurse Specialist Job Melrose area,Massachusetts USA,Healthcare

Job Overview

This role is essential in developing and maintaining an infrastructure for the systematic review and management of complex patients. The position will work closely with PHO medical directors, and leadership, TMIN case managers, TMIN Practice Optimization Coaches (POMs) and primary care providers to review patient records, analyze data, and identify practice and patient outlier utilization, and gaps in quality measures for weekly practice and medical director huddles.

Additionally, this position will be responsible for overseeing and reviewing PHO referral management. Currently, the PHO reviews every referral request out of the Hallmark Health PHO. The position would serve as a liaison to PCP practices and patients requesting an out-of-area referral.

Job Description
Minimum Qualifications

Massachusetts RN Licensure.
Five (5) years of experience in acute hospital care, ambulatory care or practice-based care, high-risk patient coordination and / or referral management.
Current Basic Life Support (BLS) Certification.
Experience in population health, quality improvement, or healthcare analytics.
Familiarity with value-based care models and risk stratification methodologies.

Duties and Responsibilities

Collaborates with PHO clinical leadership and conduct root cause analysis to identify rising and high-risk, complex patient populations.

In collaboration with PHO data analytics team, analyzes and manages patient data to generate reports and lists of complex patients for review, as well as identify outlier practices in certain utilization metrics.

Leads and coordinates weekly medical director huddles, ensuring effective case discussions and follow-up planning.

Develops and implements a structured framework for the consistent review of patients who have multiple visits to the ED and admissions for ambulatory sensitive conditions, including action planning and outcome tracking.

Works with providers and TMIN care teams to ensure alignment with best practices to support value-based care.

Serves as a clinical resource to the PHO, specifically engaging with primary care practices and serving as a liaison to the TMIN POMS providing insights and recommendations for supporting successful patient management to reduce cost and improve quality outcomes.

Monitors practice progress and ensure timely follow-up on interventions and action items.

Identifies trends and opportunities for quality improvement based on data analysis and patient outcomes and support PHO goals for high quality scores.

Ensures compliance with regulatory requirements and best practices in care coordination.

Acts as a mentor and subject matter expert, supporting providers, and practice staff in integrating patient management strategies into their workflows.

Participates actively in PHO Pod meetings and Specialty Pod meetings.

Contributes to the development of performance incentive plans for PHO Providers.

Hours

40 hours / week

This position is remote with the exception of occasional onsite meetings in Burlington, MA

What We Offer

Competitive salaries & benefits that start on day one
403(b) retirement plan with company match
Tuition reimbursement
Free on-campus parking

About Melrose Wakefield Hospital

Melrose Wakefield Hospital and Lawrence Memorial Hospital of Medford are two campuses with one community in mind : the people of north suburban Boston. Melrose Wakefield Hospital and Lawrence Memorial Hospital are distinguished by the range of high-quality clinical care and services. Our teams welcome everyone with hospitality and humanity. We focus on reducing health disparities through 40+ local health programs across a system of hospitals, urgent care locations, outpatient services, and community physicians.

Core to our values, Melrose Wakefield Healthcare's commitment to community is demonstrated by our many local health programs throughout our service area and participation in partnerships with community agencies and events, and education programs in more than 10 communities to support the wellness and health of our residents.

About Tufts Medicine

A healthcare system that works Tufts Medicine is more than a health system - we're a community that empowers people to live their best lives by reimagining healthcare, advancing knowledge and pioneering discovery. Every team member plays an integral role in realizing our vision of creating the most equitable and frictionless healthcare experience in the world. Here, you'll join an enthusiastic community that champions your growth and receive generous benefits to support you and your family's well-being.

Tufts

Medicine is an equal opportunity employer.

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are…


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Job Posting Language

Registered Nurse, RN - Population Health Nurse Specialist