Location:Hollywood, FloridaWe have an outstanding reputation for providing patient- and family-centered care that exceeds all expectations. Together, we have created an award-winning, nationally-recognized system where every effort is focused on delivering Deeper Caring and Smarter Healthcare throughout our communities. Career opportunities exist on diverse teams across our many facilities where you can search open positions and apply online to join #teamMHSflorida.Learn more below.Summary:Under the direction of the Population Health Management leadership, the Population Health Registered Nurse (PHRN) serves as a liaison between the Memorial Healthcare System (MHS), Memorial Health Network (MHN), Broward Guardian, ACHN, Memorial Physician Group (MPG), community providers, post-acute care facilities, external healthcare organizations, and the patient. The PHRN follows nursing processes and protocols and implements systems of care that facilitate care coordination and close monitoring of specially defined, high and rising risk patient populations attributed to value-based programs or MHA. The PHRN fosters an inter-professional team-based approach ensuring continuity of care extends beyond the acute care boundaries. The PHRN roles can include a focus on care management, quality, post-acute transitions, remote patient monitoring, care coordination or all of the above.Responsibilities:Performs concurrent medical record review using specific indicators and criteria. Monitors the quality, frequency, and appropriateness of healthcare delivery by post-acute providers and reports variations of plan of care, health status, or psychosocial issues to PCP and appropriate members of the care team. Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in coordination of care across the healthcare continuum.Provides complex care/case management including acute/chronic illness-oriented assessment and monitoring, medication therapy management in collaboration with the transitions of care pharmacy team monitoring, health education and self-care management. Integrates evidence-based clinical guidelines, patient and family centered care plans and protocols to promote the highest quality of healthcare delivery for a defined complex, high-risk patient population. Responsible for reviewing and co-signing modification of care plans by the Population Health Clinical Care Coordinator and Population Health Nurse. Guides and supports clinical decision making to Population Health Clinical Coordinator and Population Health Nurse for a defined low to moderate risk patient population.Provide support for the Innovative Placement Program as needed.Provides transitional care management and coordination of care for patients recently discharged from the acute care setting in collaboration with patients, family members, post-acute providers, internal and external healthcare organizations/team members and post-acute facilities. Conducts initial health risk assessment, identifies, and manages health and safety risks including social determinants of health, functional status, cognitive ability, medication clarification, and health literacy. Develops a patient-centered care plan to optimize disease management. As appropriate, discusses plan of care with patients and families. Assesses patient/caregiver capacity and willingness to participate in care model program.Responsible for interpreting and providing appropriate interventions to automated alerts and notifications in remote patient monitoring. Will coordinate with providers to assure appropriate follow up for the patient under the provider’s direction.Supports, participates, and coordinates activities for the preparation and completion of audits, chart reviews, quality reporting and regulatory reviews. Collaborates with the clinical leadership and business intelligence teams to track clinical performance and interventions that support clinical and administrative outcomes, as applicable.Establishes, maintains, and enhances relationships with post-acute care facilities and providers. Serves in an expanded healthcare role to collaborate with inter-professional colleagues, post-acute facilities, and patients/families to ensure care coordination, close monitoring, and readmission prevention for specially defined high and rising risk patient populations promoting quality and efficiency in the delivery of health care across multiple care settings.Competencies:ACCOUNTABILITY, ANALYSIS AND DECISION MAKING, CLINICAL POLICIES AND STANDARDS, CUSTOMER SERVICE, DISEASE MANAGEMENT, PATIENT AND FAMILY CENTERED CARE, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR, TEAM WORKEducation and Certification Requirements:Associates: Nursing (Required)Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate, Registered Nurse License (RN LICENSE) - State of Florida (FL)Additional Job Information:Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships. The incumbent must be able to take appropriate action when required. Ability to travel to Memorial Healthcare System locations or post-acute care facilities when needed.Required Work Experience: Three (3) years of healthcare experience. Excellent written and oral skills, with the ability to engage, inspire, build credibility and trust with peers and patients. Collaborative working style with the ability to work across different teams, areas of expertise, and adapt to various environments and clientele. Highly organized and self-motivated individual with ability to adapt to various assignments and ability to work autonomously.Other Information: Minimum: Associate of Science in Nursing; Bachelor of Science in Nursing (preferred).Additional Education Info: Bachelor of Science in Nursing (preferred)Working Conditions and Physical Requirements:Bending and Stooping = 60% Climbing = 0% Keyboard Entry = 80% Kneeling = 0% Lifting/Carrying Patients 35 Pounds or Greater = 0% Lifting or Carrying 0 - 25 lbs Non-Patient = 60% Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0% Lifting or Carrying > 75 lbs Non-Patient = 0% Pushing or Pulling 0 - 25 lbs Non-Patient = 60% Pushing or Pulling 26 - 75 lbs Non-Patient = 60% Pushing or Pulling > 75 lbs Non-Patient = 60% Reaching = 60% Repetitive Movement Foot/Leg = 0% Repetitive Movement Hand/Arm = 80% Running = 0% Sitting = 80% Squatting = 0% Standing = 80% Walking = 80% Audible Speech = 80% Hearing Acuity = 80% Smelling Acuity = 0% Taste Discrimination = 0% Depth Perception = 80% Distinguish Color = 80% Seeing - Far = 80% Seeing - Near = 80% Bio hazardous Waste = 0% Biological Hazards - Respiratory = 0% Biological Hazards - Skin or Ingestion = 0% Blood and/or Bodily Fluids = 0% Communicable Diseases and/or Pathogens = 0% Asbestos = 0% Cytotoxic Chemicals = 0% Dust = 0% Gas/Vapors/Fumes = 0% Hazardous Chemicals = 0% Hazardous Medication = 0% Latex = 0% Computer Monitor = 80% Domestic Animals = 0% Extreme Heat/Cold = 0% Fire Risk = 0% Hazardous Noise = 0% Heating Devices = 0% Hypoxia = 0% Laser/High Intensity Lights = 0% Magnetic Fields = 0% Moving Mechanical Parts = 0% Needles/Sharp Objects = 0% Potential Electric Shock = 0% Potential for Physical Assault = 0% Radiation = 0% Sudden Decompression During Flights = 0% Unprotected Heights = 0% Wet or Slippery Surfaces = 40%Shift:DaysDisclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.Wages shown on independent job boards reflect market averages, not specific to any employer. We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process.Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity.Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, gender identity or expression, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law.We are proud to offer Veteran’s Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program.Employment is subject to post offer, pre-placement assessment, including drug testing.If you need reasonable accommodation during the application process, please call (M-F, 8am-5pm) or email