Licensed Practical Nurse

Job Responsibilities

• Understands population health and value-based contracts.
• Utilizes key quality and unitization metrics of value-based programs for both wellness and chronic disease management.
• Demonstrates abilities in the Primary Care quality program including all protocols of well and chronic disease states.
• Identifies patients "at risk" for change in condition and increased utilization.
• Attends required population health training and education such as Lunch and Learns and other opportunities.
• Coordinates the primary care rooming process, relevant medical procedures, adult and pediatric patient care including, immunizations, venipuncture, point of care testing, and performs retinal scan images.
• Follows scheduling decision tree, protocols and policies for clinical procedures and appropriate use of medical equipment.
• Provides accurate and complete documentation of all facets of care including clinical calls, patient rooming questions, completion of procedures, order entry, prescriptions and patient pharmacy, and workflows.
• Adds addresses messages in a timely manner and escalates issues as appropriate.
• Utilizes and monitors MyChart messaging to support patient communication.
• Participates as a part of the patient centered medical home team during all patient visits by reviewing the patient chart of clinical gaps in care.
• Affixes outreach campaigns and tactics to close gaps in care.
• Supports and completes pre-visit planning and participates in daily huddles with the physician and care team.
• Embraces the philosophy of wellness and prevention by reminding patients of all screenings and immunizations due by the end of the year.
• Informs physician of any potential barrier identified by the patient.
• Supports and completes post ED/post inpatient discharge outreach on identified risk patient group.
• Updates care team thorough documentation and works collaboratively with Complex Care RN, Social Worker, CHW, and Population Health Pharmacist.
• Provides basic community resources to patients with social determinates in health.
• Supports and provides education and patient coaching of both wellness and chronic disease management (e.g., Diabetes Education, Colon Cancer Screening).
• Supports facilitating follow-up for post-hospital care, chronic disease management, or specialty referral.

Job Requirements

• Graduate of an approved technical, professional, or vocational program in Healthcare
• 3 - 4 Years Experience Clinical Healthcare
• Medical office flow, especially the clerical/front office tasks
• Ability to make quick decisions based on well thought out consequences/results
• Knowledge of EMR Practice management software and medical coding/billing strongly encouraged
• Basic Life Support (BLS) Upon Hire Required
• Licensed Practical Nurse Required