Reports to: Manager, Nursing
Position Overview:
Reporting to the Nurse Manager, Primary Care, the Population Health Nurse supports the organizations population health strategy by monitoring quality and population health dashboards, collaborating closely with Primary Care Providers (PCPs), identifying and addressing gaps in care, coordinating patient outreach, and overseeing key population health metrics. The Population Health Nurse partners with interdisciplinary teams to improve quality outcomes, enhance preventive care delivery, and support value-based care initiatives.
Principal Duties and Responsibilities*
- Monitor quality and population health dashboards to identify care gaps and opportunities for improvement
- Oversee key population health metrics, including preventive care, chronic disease management, and value-based care measures
- Serve as the primary nursing resource for monitoring, validating, and improving performance on organizational population health and quality metrics
- Collaborate with PCPs and interdisciplinary teams to improve patient outcomes
- Conduct patient outreach and care coordination activities
- Analyze quality performance trends and prepare reports
- Support value-based care and quality improvement initiatives
- Establish patient care goals through education, information, and guidance for patients and families
- Develop partnership with service providers, families, and patients in addressing gaps in care and coordinate reosurces/outreach
- Ensure coordination and continuity of care, including engagement with community resources and family support
- Maintain close communication with the Primary Care team to ensure consistency in care planning
- Maintain accurate, detailed, and up-to-date reports and records
- Acquire and maintain knowledge of available patient services, insurance benefits, and reimbursement processes
- Act as a resource and advocate for patients, clinicians, and families to ensure appropriate care and services
- Assist patients in navigating access to MIT Health services and external specialists, including mental health resources
- Collaborate with the Primary Care nursing team as needed
- Stay informed on current research related to ambulatory nursing and care coordination, and contribute to program development
- Perform other duties as assigned
Minimum Required Education and Experience:
- Graduate of an accredited nursing program. Bachelor’s degree required.
- Licensure: Current RN license in Massachusetts. CPR Certified
- Minimum 3 years of nursing experience in population health, ambulatory care, primary care, chronic disease management, case coordination or related clinical setting
- Demonstrated experience utilizing patient registries, quality dashboards, and population health tools to identify care gaps and implement interventions that improve patient outcomes
- Knowledge of preventive care guidelines, chronic disease management principles, risk stratification methodologies, and evidence-based clinical practice
- Experience collaborating with interdisciplinary care teams to achieve quality and patient care goals
- Strong analytical, communication, organizational, and time-management skills