Licensed Practical Nurse- Population Health

Southern Ohio Medical Center•Portsmouth, OH

2d•Remote

About The Position

Works under the supervision of the Population Health LPN Nurse Manager. The Population Health LPN’s primary function is to support Population Health through conducting proactive outreach to patients, closing care gaps, and coordinating services to improve quality of care. This role collaboratively works with Physicians, Advanced Practice Practitioners, diabetic educators, pharmacy, social work, and payer-specific navigators to engage patients in preventive care, chronic disease management, and post-discharge follow-up. This position will serve all clinics and patients, regardless of payer.

Requirements

Graduate of an accredited Practical Nurse program
Active LPN Ohio License
2+ years of experience

Nice To Haves

Working knowledge of Microsoft Word, PowerPoint and Excel
Experience with data visualization tools

Responsibilities

Conduct outbound and inbound patient outreach via phone, portal, and other communication methods to support value-based care programs.
Identify and address care gaps related to preventive screenings, chronic conditions, and quality measures associated with Population Health.
Assess patients over the phone and escalate to physicians and APPs as appropriate.
Educate patients on recommended care, medication adherence, follow-up appointments, preventative care, and other healthcare specialties.
Document outreach activities, assessment, and interventions accurately in the EHR.
Performs post-discharge and transitional care follow-ups as assigned.
Support quality improvement initiatives and audits as needed.
Maintains accurate and risk-stratified patient panels for physicians and APPs, serving as an extension to the clinics.
Serve as a coordinator to align the needs of the patient with appropriate members of the care team.
Identify and assist the patient with support systems and community resources.
Collaborates with and acts as a resource for other departments, physicians, advanced practice providers, nurses, and other clinicians for population health data.
Performs other duties as assigned.