Population Health Nurse (RN) - Duke Primary Care Louisburg

Population Health Nurse (RN) – Duke Primary Care Louisburg Location: 205 Sandalwood Ave, Suite C, Louisburg, NC 27549 Hours: 8 am – 5 pm Monday to Friday What You Will Do The Population Health Nurse plays a key role in improving geriatric care through prevention, comprehensive assessments, and personalized care coordination. They support smooth transitions across care settings, educate and advocate for patients, and collaborate closely with care teams to deliver evidence‑based, patient‑centered outcomes that strengthen individual and community health. Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures. Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community. Monitor system access to care, services, and treatment, including linkage to the medical home. Address the total individual, including medical, psychosocial, behavioral, and spiritual needs, involving the patient and their support systems in decision‑making. Use a patient‑centric, collaborative partnership approach to assist the patient with improved self‑management. Apply teaching and learning theories to assist patients and families with the physical and emotional impact of body changes and chronic illness. Communicate and coordinate with all provider(s) and member(s) of the care team to minimize fragmented care, including transitions from hospital to home or community facilities. Monitor quality and effectiveness of interventions by setting long‑term or short‑term specific, measurable goals. Access and systematically use data from multiple sources such as patient medical records, claims, and program metric reports to target recipients and providers for outreach, education, and intervention. Advocate for patients and supporting providers to ensure delivery of appropriate, evidence‑based care. Facilitate quality improvement activities that educate, support, and monitor providers regarding evidence‑based care for best practice/National Standards of Care. Utilize innovative nursing and population management tactics to support health throughout the continuum of care. Participate in quality/performance improvement programs, product evaluation, outcomes evaluation studies, and/or clinical research. Provide clinical experience in a preceptor role for students and orient new nursing staff through formal and informal one‑on‑one teaching. This position may require home visits; details are available upon request. Activities and patient acuity levels may create a stressful atmosphere. What You Will Need Education BSN required. Experience 3 years of nursing experience required. Degrees, Licensure, and/or Certification Current RN licensure in North Carolina required. Knowledge, Skills, And Abilities Successful candidates will be organized, motivated by a fast‑paced environment, able to manage multiple tasks or projects simultaneously, and proficient in reviewing and assessing needs quickly. Strong with the use of computer software tools and data files. Comfortable with continuous change and self‑initiating. Able to complete documentation efficiently. Ability to maintain strict confidentiality. Promote programs and services to the community. Build effective and trusting relationships with patients and peers. Use motivational interviewing and active‑listening skills when assessing patient conditions, problems, and interests. Use conflict‑resolution skills when reaching consensus about plans of care and treatment decisions. Demonstrate confidence, compassion, political savvy, and attention to detail. Use data to analyze trends and verify data. Proficient in reviewing medical records and other patient care information. Self‑directed and able to organize multiple tasks or projects simultaneously. Job Code: 00005555 POPULATION HEALTH NURSE Job Level: G1 Seniority level Mid‑Senior level Employment type Full‑time Job function Health Care Provider Hospitals and Health Care Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status. Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. All members of our community have a responsibility to uphold these values. Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department. #J-18808-Ljbffr Duke Health