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Population Health and Wellness Nurse

Facility: CHS Services Location: Rockville Centre, NY Department: Physician Strategy-Quality Category: Nursing / Nursing Leadership Schedule: Part Time Shift: Day shift Hours: 8:30 am - 2:45 pm ReqNum: 6047963

Catholic Health is an integrated health care delivery system with some of the region's finest health and human services agencies. CH includes six hospitals, three skilled nursing facilities, a regional home nursing service, hospice and a multiservice, community-based agency for persons with special needs. Under the sponsorship of the Diocese of Rockville Centre, CH serves hundreds of thousands of Long Islanders each year, providing care that extends from the beginning of life to helping people live their final years in comfort, grace and dignity.

The Population Health and Wellness Nurse will serve in an expanded nursing role to perform Annual Wellness Visits per Medicare guidelines, promote preventative patient care, offer screening services, and coordinate disease management services with the provider, patient and their family. Reviews health maintenance and educates on same. Collaborates with provider to order due or overdue preventive health tests and immunizations. Assists with integrating identified patient needs, intervention pathways, clinical guidelines and diagnostic tests to develop individualized plans of care. Offers nursing expertise in the implementation, development and support of practice transformation models, e.g. Advanced Primary Care (APC) and Patient Centered Medical Home (PCMH). Requires travel to various physician practices within the region.


  • Performs Annual Wellness Visit in accordance with Payer and CH guidelines.
  • Assesses the healthcare, educational and psychosocial needs of the patient/family and involves them in establishing a treatment plan based on realistic goals and interventions.
  • Investigates healthcare options and facilitates communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify interventions for treatment.
  • Uses motivational interviewing and shared decision-making modalities as appropriate to enhance patient engagement.
  • Educates patient, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and makes referral to appropriate Care Coordination services as needed.
  • Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. Coordinates laboratory and diagnostic tests for disease management and value-based payment programs.
  • Collects and enters data and patient information into the medical record according to department and CH standards.
  • Attends and participates in professional and nursing continuing education programs and professional development opportunities.
  • Reviews the current literature regarding effective teaching/learning strategies and disease management strategies and incorporates the appropriate techniques into practice.
  • Incorporates excellent written, verbal, and listening communication skills, team-building skills, and critical thinking skills in disease management practice.


  • Demonstrates good organizational skills and effective communication skills (verbal and written).
  • Works independently and utilizes critical thinking skills.
  • Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
  • Demonstrates ability to work autonomously and be directly accountable for practice.
  • Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
  • Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving and decision-making, priority setting, work delegation and work organization.
  • Ability to review and comprehend various sources of clinical and population health data.
  • Demonstrates the ability to obtain an accurate patient history, establish treatment goals, establish working relationships with referral sources and communicate care plans as directed by the medical provider.
  • Accesses and evaluates available resources to meet a patient's needs, identifies resource gaps and develops internal and external resources and linkages to eliminate these gaps.
  • Demonstrates ability to gather, review, analyze, and interpret data to inform development of programs and improved health outcomes
  • Displays cooperative behavior. Interacts positively and effectively with others to promote a team environment.
  • Performs other duties as necessary to maintain the overall efficiency and continuity of the practice.
  • Is proactive in identifying, reporting and participating in the resolution of any potential or actual patient safety issues.
  • Demonstrates knowledge of and conduct himself/herself in conformity with the CH Compliance Assurance Program and Standards of Conduct. Employee shall receive a copy of the CH Compliance Program Handbook and be aware of the CH Helpline. Employee will perform all work activities according to the highest ethical and legal standards.
  • Conducts himself/herself in conformity with the HIPAA Compliance Program and applicable institutional policies and procedures for patient privacy.
  • Plays an active role in the CH Information Security Awareness Program by following and supporting all CH information security policies and procedures to the best of their ability. This will include reporting any suspected fraud, abuse, or violation of policy to the appropriate management or reporting mechanism.
  • Supports the organization's mission and values by exhibiting the following behaviors: excellence and competence, collaboration, innovation, respect, commitment to our community, and accountability and ownership.
  • Current, unencumbered NYS RN license required.
  • Bachelor's degree required, master's degree preferred.
  • Prior population health experience preferred; AWV familiarity a plus.
  • Minimum of 3 years ambulatory experience required
  • Strong background in ambulatory care prevention, health promotion, condition management, case management and discharge planning.
  • Mastery of theories, principles and methodologies underlying population health management and clinical preventative services.
  • Knowledge of contemporary practice transformation models, e.g., PCMH, APC
  • Proficient in Microsoft Office (Excel, Power Point, and Microsoft Word), Outlook (email), and internet familiarity is required.
  • Knowledge of EMR (EPIC preferred)

At Catholic Health your well-being comes first, with comprehensive compensation and benefits; our offerings go beyond the basics. In addition to multiple medical plans, life insurance, generous paid time off and flexible spending accounts, we also offer substantial tuition reimbursement, an employer funded pension plan and several savings plan options for your future.

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