Population Health Nurse

IntusCare is seeking a dynamic and experienced Population Health Nurse who will support the IntusCare customer PACE Interdisciplinary Team and other stakeholders through robust data analysis to promote care coordination, prevent hospitalizations and minimize unnecessary and/or unwanted participant care.

The Population Health Nurse will work within a structured population health management program that assists clients in identifying care gaps leading to increased service utilization as well as equipping clients to design, pilot, and scale customized clinical care protocols focused on increasing individual well-being and reducing the costs of care.

What We Do

IntusCare is a healthcare analytics platform that synthesizes healthcare data to identify risks, visualize trends, and optimize care for PACE programs. IntusCare empowers care providers to mitigate high risk events and equips executives with the tools to make informed decisions based on comprehensive clinical and operational data. Our mission is to catalyze data driven change to achieve high-value, multi-disciplinary care for older adults. In addition, IntusCare offers a broad range of technical assistance and consulting services to support PACE programs under development and existing programs that are growing and evolving to meet the needs of their communities.

In This Role You Will:

• Design, implement and manage population-based care coordination activities.

• Monitor patient outcomes and analyze data to measure the effectiveness of clinical initiatives

• Using the IntusCare application, EMR and other data sources, assess the health and care needs of PACE participant populations and subpopulations:

  • Identifying PACE participant subpopulations at risk for decline and/or hospitalization due to comorbid conditions and utilization patterns.

  • Identifying groups and subpopulations that will benefit most from coordinated health care promotion activities

  • Coordinate and communicate with the PACE program Medical Director and other stakeholders to develop and implement strategies to address unique care needs of subpopulations to promote health and well-being

  • Follows the progress of population management strategies and reports progress to IntusCare Chief Population Health Officer and PACE program Medical Director and other stakeholders to facilitate continued strategy iterations

• Using the IntusCare application, EMR, and other data sources, identify high risk participants with imminent risk for decline and/or hospitalization:

  • Present participant specific conditions and scenarios to the PACE Interdisciplinary Team and primary care care teams to focus resources daily for participant follow up to address and resolve identified risks

  • Follow the progress of the participant to evaluate and communicate the effectiveness of the implemented intervention/treatment plan

  • Identify and communicate blockers to participant access to care

• Facilitate “shared goal model” within and across settings to achieve coordinated high-quality care that is participant and caregiver-centered

Qualifications:

• 3 to 5 years of population health management experience.

• Current RN license

• Proven experience working in risk based integrated models of care

• Ability to use data to drive decisions and collaboration with internal and external stakeholders

• Strong critical thinking skills and strong, autonomous self-management

• Comfortable with rapid cycle improvement and thrives in fast paced performance improvement environments

• Ability and willingness to identify and initiate process improvement strategies to implement and iterate on system changes

• Strong strategic thinking, problem solving, and decision-making skills.

• Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies

What We Offer

• A chance to be a part of a trailblazing team in healthcare technology

• Competitive salary and equity package

• Comprehensive benefits including health, dental, and vision insurance

• A collaborative, inclusive, and dynamic work environment

• Opportunities for professional growth and development

Compensation: The salary range for this role is $85K–$95K. We expect the ideal candidate to fall near the midpoint of this range, though final compensation will be determined based on experience, skills, and organizational needs.

Work location: This is a fully remote role based in the United States.

Sponsorship: This position is not eligible for sponsorship.