The Clinical Nurse-ACO Nurse works in collaboration with the primary care provider and all members of the health care team. This nurse assesses healthcare needs that require additional follow up by primary care provider and assists patients in scheduling appropriate follow-up. Knowledgeable of community resources and assists patients in connecting with those resources. Serves as a patient advocate.

Supervisory Responsibilities:

• None.

Duties/Responsibilities:

• Identification of Medicare patients appropriate for Medicare Annual Wellness Visits (MAWV)
• Work collaboratively with clinical teams to accomplish MAWV in an efficient manner for patients and team.
• Identification of those patients requiring Transitional Care Management (TCM)
• Execution of initial engagement to meet TCM requirements
• Identification of private insurance payers' patients that require Annual Physical Exams
• Collaborate with the ACO team to ensure patient needs are met
• Critical thinking skills to plan and organize nursing processes to coordinate care for the patient.
• Develop knowledge of preventive services and clinical guideline recommendations for those
  services and be able to share this information in an easy-to-understand way.
• Appropriately documents within the electronic record or via paper, in the event the systems are down.
• Utilizes appropriate protocols in delivering patient care.
• Performs all other duties as assigned.

Required Skills/Abilities:

• Knowledge of infection prevention/control practices to maintain a safe environment
• Ability to carry out written and oral instructions and to exercise judgment for patient care
• Ability to multitask and present information timely and accurately in a fast-paced environment.
• Ability to work cooperatively with people and to maintain an objective attitude.
• Ability to exercise tact and initiative while being supportive in challenging situations
• Excellent written and verbal communication skills.

Education and Experience:

• Graduation from an accredited school of nursing.
• Licensed to practice as a Licensed Practical Nurse (LPN) in the state.
• 2 years of experience as an LPN, preferred

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to assist patients to stand from a char, if needed.

Glendive Medical Center (GMC) conforms to all the laws, statutes, and regulations concerning equal employment opportunities and affirmative action. We strongly encourage women, minorities, individuals with disabilities and veterans to apply to all of our job openings. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without any regard to race, color, religion, gender, national origin, disability status, protected veteran status, sexual orientation or gender identity, or any other characteristic protected by law.

GMC promotes a drug and alcohol-free workplace. Offers of employment are contingent upon successfully passing pre-employment screenings.