LPN Population Health ACO

• DEPARTMENT: 18390 – NCH ACO
• LOCATION: 1100 Immokalee Road, Naples, FL, 34110
• WORK TYPE: Full Time
• WORK SCHEDULE: 8 Hour Day

ABOUT NCH

NCH is an independent, locally governed non-profit delivering premier comprehensive care. Our healthcare system is comprised of two hospitals, an alliance of 700+ physicians, and medical facilities in dozens of locations throughout Southwest Florida that offer nationally recognized, quality health care.

NCH is transforming into an Advanced Community Healthcare System(TM) and we’re proud to: Provide higher acuity care and Centers of Excellence; Offer Graduate Medical Education and fellowships; Have endowed chairs; Conduct research and participate in national clinical trials; and partner with other health market leaders, like Hospital for Special Surgery, Encompass, and ProScan.

Join our mission to help everyone live a longer, happier, healthier life. We are committed to care and believe there's always more at NCH – for you and every person we serve together. Visit nchjobs.org to learn more.

JOB SUMMARY

The LPN Population Health provides coaching and diseases management services to identified populations. Has adequate understanding of all required documentation for post inpatient, Transition of Care (TCM) visit types per CMS guidelines. Interviews patients to ensure they have a good understanding of discharge instructions, medication instructions, and make themselves available to answer any outstanding patient questions. Helps the Population Health analysts to complete outreach to those patients that may be outstanding on one or more of their quality care gaps and facilitates appointments to close those gaps when appropriate. Supports evidence-based practice and medical home/care coordination principles. 

ESSENTIAL DUTIES AND RESPONSIBILITIES

– Other duties may be assigned.

Provide coaching and disease management services to identified populations.

· Provides individual health coaching via telephone.

· Manages patient populations, including care transitions.

· Collaborates with patients, caregivers, and providers to develop a comprehensive plan of care.

· Utilizes motivational interviewing to support in understanding adherence to discharge instructions.

· Supports medical home and care coordination principles; follows/completes assigned activities/protocols.

· Participates in data collection/monitoring and formulation of process improvement plans.

· Identify medication adherence barriers and works with the patients, providers, and other resources to alleviate those barriers.

· Complete clinical outreach to patients when identified as having outstanding care gaps by insurance plans or their PCP or Specialist.

· Timely and accurate documentation in patient charts; relaying information & instructions to patient/family. Document all interventions, phone calls, patient/family responses, medication dispensed or prescribed, hospital data, etc. in medical record/EMR.

· Demonstrates knowledge of safe medication administration; administers prescribed medications and treatments in accordance with nursing standards.

· Utilizes electronic referral process to complete requested physician referrals to NCH Healthcare Group specialists and ancillary services.

· Knowledgeable about treatments administered and studies performed, as well as any preparation of the patient which may be required prior to the test being performed.

Demonstrates sound clinical judgment.

· Identifies educational needs of patient/family and provides instruction/referrals to meet self-management goals.

· Identifies priorities and organizes work accordingly.

· Follows evidence-based practices and standards of care.

Planning/Consultation

· Serves as an expert clinical leader within ambulatory clinics.

· Functions as a change agent using effective communication skills.

· Develops productive relationships with leaders, physicians, staff, and community partners.

· Works collaboratively with other care team members to influence positive patient outcomes.

· Supports team-based care model.

· Coordinates post inpatient discharge appointments with PCP.

EDUCATION, EXPERIENCE AND QUALIFICATIONS

· Minimum of High School or GED required.

· Minimum of 2 years’ experience in a related field required.

· Licensed as Licensed Practical Nurse in the State of Florida.

· Basic Life Support (BLS) certification required from the American Red Cross or American Heart Association.

· Demonstrates competencies in nursing practice, with a focus on quality.

· Basic computer skills with excellent verbal and written communication skills.