Population Health Nurse - Chronic Care Management The Population Health Nurse will promote effective partnerships between patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines that coordinates care for patients with chronic disease and effectively manages care transitions. He or she will partner with other YGH staff for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness. He or she will provide effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk.

Roles and Responsibilities:

Provide a coordinated, strategic approach to identify new or manage an established chronically ill patient population. Arrange patient population according to risk to effectively and efficiently manage patients. Determine frequency of need for provider appointment. Maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact. Collaborate with YGH staff to implement effective internal tracking systems for patients such as patient panels, annual wellness visits, transition of care follow-up calls/timely provider visits, and non-face-to-face monthly encounters. Ensure all required elements are documented for CCM and related AWV component billing. Ensure office staff has an effective internal tracking process to capture results, medication acquisition, missed appointments, and adherence to follow-up appointments. Develop a process to track Annual Wellness Visits (AWV) scheduling and ensure that patient records are reviewed appropriate to identify care gaps prior to visit with the provider visit. Post reminders to secure that all co- illnesses are discussed and documented during AWV. Participate in daily/weekly meetings with providers and staff. Identify scheduling opportunities, determine special needs for patients arriving that day, identify patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments needing rescheduling. Ensure sharing of positive patient stories or compliments involving care team efforts. Provide clinical health coaching interventions to motivate patients and families toward successful self-management of chronic disease. In collaboration with the physician or qualified healthcare provider, develop a care plan based on mutual goals with the patient, family, the provider's emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed. Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider. Establish counseling services/resources within the practice to assist with obesity, tobacco cessation, diabetes prevention/management, depression, anxiety and managing cardiovascular disease.

Requirements:

Current licensure as a Licensed Practical Nurse. Previous experience in caring for chronic disease patients preferred. 2 years' experience in provider practice or clinic health setting preferred. Possesses strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate to patients with complex medical, emotional, and social needs. Attention to detail and accuracy of documentation of records. Has the ability to work in a high-volume caseload environment and deal effectively with rapidly changing priorities. Possesses organizational, leadership, communication, education, collaboration, and counseling skills. Previous Care Coordination, Case Management, Home Health or Behavior Health experience preferred. Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred. Ability to identify and implement appropriate patient communication strategies. The demonstrated ability to work constructively with all disciplines related to caring for patients within the community.

Essential Qualifications:

Core values consistent with a patient/family-centered approach to care. Demonstrates professional and effective written and verbal communication skills. Demonstrates a positive, respectful attitude and professional customer service. Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations. Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns. Recognizes and responds to opportunities for improvement. Provides mentoring/coaching of other provider practice team members. Cultivates effective partnerships, effectively collaborates with all practice providers. Demonstrates understanding in use of IT resources and patient databases. Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.

Job Type:

Full-time Benefits:

401(k) 401(k) matching Dental insurance Employee discount Health insurance Life insurance Paid time off Referral program Retirement plan Vision insurance

Work Location:

In person