Annual Wellness Nurse/Population Health Facilitator - LPN

Choose a career to make a difference in people's lives every day at Fisher-Titus.

About Fisher-Titus

Fisher-Titus proudly serves the greater Huron County area’s 70,000-plus residents by providing a full continuum of health and wellness care from heart and cancer care to outpatient services such as lab, imaging, and physical rehabilitation.

• Vision: Be the first choice for healthcare and employment within our community
• Mission: Deliver compassionate and convenient care to the highest level of excellence that promotes lifelong health and wellness for our community

About the role

The Annual Wellness Nurse/Pop Health Facilitator works collaboratively with physicians and the care team to ensure patient adherence to the medical plan of care and/or evidence-based medicine guidelines, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals; including self-management goals, and contact schedules.

Responsibilities

• Communicate with populations of patients via telephone, electronically, correspondence or otherwise to support patient adherence to plan of care and/or evidence-based medicine guidelines.
• Maintain an active case load of "at risk" patients using identification and stratification tools, direct referrals from the patient's healthcare team (physician, Care Coordinator, hospital case manager, etc.) and other clinical knowledge.
• Work with "at risk" patients and families on self-management support including:
  • Setting short and long-term goals for self-management of chronic disease.
  • Addressing medication adherence in patients not meeting outcome goals.
  • Creating a plan for health behavior change.
• Perform individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes.
• Communicate with patients face-to-face, by telephone, or by email.
• Communicate a plan for healthcare needs between physician/office visits.
• Provide needed patient education regarding specific health care skills and general disease concepts by supplying informational materials, directing the patient to health plan resources, approved websites or community resources.
• Work toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
• Float and/or work at other locations to support operational needs.

This position requires expertise in the nursing process, using critical thinking skills to plan and coordinate care. The AWN is responsible and accountable for direct and indirect patient care for designated patient populations. Although primarily performed by an LPN, the role of an Annual Wellness Nurse can be accomplished as an RN with understanding that salary will be established at an LPN level.

Qualifications

• Full time

Benefits

• Comprehensive Benefits Package: Medical & Dental coverage
• 401K match
• Paid time off
• Tuition assistance
• Shift, weekend, and PRN differentials