Population Health Nurse - Duke Primary Care Pediatrics

Population Health Nurse - Duke Primary Care Pediatrics

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke Primary Care

Pursue your passion for caring with Duke Primary Care, which offers family, adolescent, and internal medicine services as well as urgent, general pediatric, and virtual care at nearly 50 clinic locations across central North Carolina.

Duke Nursing Highlights:

• Duke University Health System is designated as a Magnet organization
• Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
• Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
• Duke University Health System has 6000+ registered nurses
• Quality of Life: Living in the Triangle!
• Relocation Assistance (based on eligibility)

Population Health Nurse - Duke Primary Care Pediatric

Duke Primary Care Pediatrics provides expert, family-centered care for children from newborns through teens. Their services include well-child and sick visits, immunizations, developmental and behavioral screenings, chronic condition management, and preventive health guidance. With convenient same-day and virtual visits, lactation support, and coordination with Duke's pediatric specialists, these departments deliver high-quality, accessible care across multiple locations, supporting the health and well-being of every child and family.

Location: Hybrid

Schedule: Monday - Friday, 8am - 5pm

What you will do:

The Population Health Nurse partners with pediatric patients with complex health needs, delivering care and education through a dynamic blend of educational telehealth visits and care coordination. This role guides children and their families in managing chronic illnesses, develops and coordinates individualized care plans, and ensures connection to the right resources and support. As an integral member of an interdisciplinary team, the nurse helps families navigate care transitions, empowers them with knowledge and tools, and drives improved, patient-centered health outcomes.

• Deliver specialized nursing care, create individualized care plans, and educate patients and families while using clinical judgment and following established policies.
• Identify the educational needs of patients and caregivers related to their condition, recovery, and transition back to home and community life.
• Ensure patients have access to the right care, services, and resources, including coordination with their medical home.
• Address the whole person medical, emotional, behavioral, psychosocial, and spiritual needs for truly comprehensive care.
• Actively involve patients and their support systems in decision-making, using a collaborative approach to build self-management skills and encourage long-term healthy behaviors.
• Communicate and coordinate with providers and care team members to reduce gaps in care, especially during transitions like hospital-to-home.
• Set measurable goals for patients and monitor the quality and success of interventions over time.
• Use data from medical records, claims, and program reports to identify patients who need outreach, education, and additional support.
• Advocate for patients and work closely with providers to ensure care is evidence-based and aligned with national standards.
• Support quality improvement initiatives by educating providers, tracking outcomes, and helping implement best practices.
• Apply innovative population health strategies to improve health outcomes and keep care cost-effective.
• Participate in performance improvement projects, product evaluations, and clinical research to advance patient care.
• Serve as a preceptor and mentor for nursing students and new staff, providing guidance and coaching in both formal and informal settings.
• May perform home visits as needed (specific details provided by the department).
• Manage the demands of a fast-paced, high-acuity environment with professionalism and resilience.

What you will need:

Education

• BSN

Experience

• 3 years of nursing experience required
• Pediatric experience preferred

Degrees, Licensure, and/or Certification

• Current RN licensure in the state of North Carolina required.

Knowledge, Skills, and Abilities

The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are:

• Organized and motivated by a fast-paced environment
• Able to manage multiple tasks/projects simultaneously
• Proficient in review and assess needs quickly
• Strong with the use of computer software tools and data files
• Comfortable with continuous change and self-initiating
• Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics)

Distinguishing Characteristics of this Level

Additional job expectations include the ability to:

• Maintain strict confidentiality
• Promote programs and services to community
• Build effective and trusting relationships with patient/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, as well as attention to detail to apply these skills as decisions dictate
• Use data to analyze trends and to verify data
• Self-directed and able to organize and manage multiple tasks/projects simultaneously
• Ability to promote programs and services to community
• Proficient in review of medical records and other patient care information