Patient Care Advocate II (PCA II)

Clinical Care & Visit Facilitation

• Facilitate in-home telehealth visits between the WellBe APP or Physician and the patient, including initial patient assessments, urgent visits and ongoing follow-up visits as appropriate to patient need.
• Check and record health vitals — including weight, blood pressure, heart rate, lung sounds, and blood-sugar levels — and document health changes observed during the visit or reported by the patient.
• Complete and document a thorough home-safety inspection during patient visits.
• Provide direct patient-care support and patient education at the direction of the assigned Provider, within the LPN scope of practice.
• Complete minimally-invasive patient screenings and point-of-care testing (POCT), and clearly explain POCT to geriatric patients.
• Safely and competently perform venipuncture and capillary blood collection for geriatric patients in home settings, subject to applicable state laws and restrictions.
• Safely and competently perform intravenous therapy, subject to applicable state laws and restrictions.
• Support the Comprehensive Initial Visits, Follow-up Visits, and Urgent Visits. Complete drop-in visits for the unengaged and disengaged patients and support open HEDIS.
• Conduct check-in visits/calls to our lower acuity patients, enhancing our “call us first” model.
• Escalate patient clinical concerns to the APP, Community Operations Director (COD), or Community Medical Director (CMD).

Patient Advocacy & Care Coordination

• Develop rapport and deliver exceptional, compassionate in-home service; provide positive customer service and treat all patients and staff with respect.
• Assemble and schedule patient appointments with the WellBe team and coordinate specialist appointments and diagnostic tests.
• Answer patients’ clinical questions strictly within the boundaries of the SOP.
• Explain WellBe processes and the care journey.
• Review patient-care interventions and assess patient needs for transitions of care, end-of-life discussions, palliative-care interventions, and medication adherence.

Quality, Documentation & Team Collaboration

• Support the APP in ongoing panel management and quality-of-care efforts; utilize HEDIS tracking tools to meet and improve HEDIS / STARS performance and close gaps, including medication adherence.
• Contribute complete, accurate, and timely data to patients’ records and ensure all required clinical and non-clinical documentation is in the EMR; complete and submit all documentation daily.
• Collaborate with the interdisciplinary team and participate in regularly scheduled team and Interdisciplinary Team (IDT) meetings, providing additional information on patient and family interactions.
• Build relationships with local community providers and caregivers to maintain WellBe’s presence and reputation in local markets.
• Attend all required trainings, including equipment / device training; complete ongoing education as additional skills and protocols are added.

Required Skills And Abilities

• Strong communication skills, with the ability to effectively interact with patients, families, and remote healthcare professionals.
• Ability to work independently and make sound decisions while adhering to established protocols, guidelines, and the LPN/LVN scope of practice.
• Excellent organizational and time-management skills to balance in-person visits, telehealth facilitation, and administrative tasks.
• Familiarity with electronic medical records (EMR) systems and strong computer skills, including Word, Excel, and PowerPoint.
• Understanding of risk assessment, quality measures, and full-risk / value-based care.
• High level of professionalism and a strong geriatric customer-service focus.
• Experience working with culturally diverse and underserved populations.

Physical and Mental Requirements

• Ability to stand/sit for extended periods.
• Visual acuity and fine motor skills.
• Ability to travel to patient homes and facilities as needed.