Position Summary: The Population Health Coordinator (PHC)is a licensed practical nurse (LPN) who supports the development of patient-centered, team-based care with the implementation of remote patient monitoring, chronic care management, and value-based care programs. He/she will support Crisp Regional Hospital Primary Care Physicians (PCP) and practice managers in managing patient panels by using a population health management informatics tool. By gathering and organizing patient data, the PHC works to identify patients’ unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and their care team. The goal of the Population Health program is to facilitate high-value, patient-centered care that improves timely access to, and provision of preventive services and chronic disease treatment. The PHM will also assist clinical providers through in-person education and reporting. Basic Qualifications: - Education: Graduate from an accredited School of Nursing with a Licensed Practical Nurse degree
- Experience: Two (2) or more years of experience in a primary care setting. Preferred experience in value-based incentive contracts, population health, and quality.
- Licensure, Registrations & Certifications: LPN
Essential Job Responsibilities: - Develops an understanding of the primary care practice requirements for optimal, coordinated population health and determine patients based on need for Chronic Care Management (CCM) and/or Remote Patient Monitoring (RPM)
- Work as an effective team member
- Manage Crisp Regional Hospital value-based contracts
- Facilitate CCM platform to support patients with multiple chronic diseases and assist in the coordination of patient care
- Manage patient registries and provide the PCP practice with data required to meet the health needs of the patient
- Monitor hospital admissions and emergency room utilization to assess for need for CCM and/or RPM
- Verify insurance eligibility/coverage for CCM and/or RPM services
- Collaborate with providers to enter standing orders, alerts, and reporting
- Order devices from RPM vendor and ensure delivery and set-up
- Monitor RPM vendor portal to track enrollments, orders entered and signed by providers, and consent obtained by patient
- Serve as the contact between vendor and CRH
- Manage low alerts, communicate moderate alerts to the provider, and develop an action plan as directed
- Manage billing reports for RPM and CCM services
- Contribute to teamwork within and between departments
- Perform all job duties in compliance with applicable federal, state, local, and company policies and procedures
- Perform other related job duties as assigned
Scope of Practice: - Displays core competencies of accountability and measurement, engaging and cooperative style, innovation, and entrepreneurial spirit, with a commitment to quality, safety, and service
- Documents legibly and in accordance with established hospital organization policies and procedures
- Converses with peers, physicians, and other staff in a manner which conveys mutual respect and understanding, included compliance with organization’s Operation Excellence Standards
- Consistently practices within the scope of practice as authorized by job description, rules, and regulations of Georgia Board of Nursing, and Crisp Regional Health System policies and applicable protocols
- Meets competencies for specialty area
- Demonstrates competence in providing age specific care to populations served
- Will at all times be in compliance with all applicable statutes, rules, regulations, and requirements of all federal, state, and local commissions, boards, bureaus, and agencies
- Completes all required professional education including continuing nursing education hours and mandatory in-services to maintain professional licensure
- Mentors new employees as requested
- Provides appropriate level of clinical and educational services as needed and that is age and condition appropriate
- Provides guidance in performance improvement (PI) projects
- Demonstrates positive interpersonal skills when communicating with patients, families, coworkers, and physicians, as measured by observation and through patient and family satisfaction survey results
- Demonstrates adherence to CRHS Standards of Behavior as measured by peer and supervisor observations
- Demonstrates reliability as measured by compliance with the CRHS Time and Attendance policy
- Demonstrates professional conduct by maintaining strict confidentiality, as measured by valid complaints given to the supervisor or director
- Performs other related job duties as assigned
- Strong computer skills including working knowledge of Microsoft Office: Word, Excel, and PowerPoint
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