Patient Care Advocate II (PCA II)

Wellbe Senior Medical•Syracuse, NY

4d•Remote

About The Position

The Patient Care Advocate II (LPN/LVN) is a licensed, field-based member of WellBe’s interdisciplinary geriatric care team who delivers white-glove, high-quality, in-home care to frail, poly-chronic, elderly Medicare Advantage patients in the comfort of their own homes. This role combines patient-advocacy, care-coordination, and quality (HEDIS) responsibilities with clinical and telehealth visit-facilitation responsibilities. Practicing within the LPN/LVN scope of practice and at the direction of the assigned Provider, the Patient Care Advocate II conducts in-person patient visits, facilitates in-home telehealth consultations with an APP or Physician, captures and documents clinical data, supports patient education, and serves as the local-market connector for patient support services across the WellBe platform. The role models the WellBe mission and values, works closely with the provider and social-work teams, and functions as part of an integrated, interdisciplinary care team with no direct-report responsibility. The incumbent follows the rules and regulations of state and federal regulatory agencies and other certifying bodies for their region. Daily, local travel to meet patients and engage the community is an essential part of the role.

Requirements

High-school diploma / GED
Active, unrestricted Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) license, with residency, in the state of service.
Minimum of two (2) years as an LPN/LVN in a direct, patient-facing care-delivery role.
Current BLS / CPR certification for healthcare providers, or willingness to obtain.
Demonstrated ability to perform high-quality venipuncture and capillary draws on geriatric patients in home settings (where required by market and consistent with state law).
Valid driver’s license with an acceptable driving record, and proof of an active auto-insurance policy.
Ability to stand/sit for extended periods.
Visual acuity and fine motor skills.
Ability to travel to patient homes and facilities as needed.
Must be legally authorized to work in the United States without the need for employer sponsorship now or in the future.
Must be able to perform job duties in a manner that ensures the safety of themselves, coworkers, patients, and the public.
Must have full cognitive and physical functioning at all times.

Nice To Haves

Prior telehealth experience preferred.
Previous experience in home care, hospice, palliative care, or geriatrics strongly preferred; other complex patient-health-care experience also beneficial.
Familiarity with electronic medical records (EMR) systems and strong computer skills, including Word, Excel, and PowerPoint.
Understanding of risk assessment, quality measures, and full-risk / value-based care.
High level of professionalism and a strong geriatric customer-service focus.
Experience working with culturally diverse and underserved populations.

Responsibilities

Facilitate in-home telehealth visits between the WellBe APP or Physician and the patient, including initial patient assessments, urgent visits and ongoing follow-up visits as appropriate to patient need.
Check and record health vitals — including weight, blood pressure, heart rate, lung sounds, and blood-sugar levels — and document health changes observed during the visit or reported by the patient.
Complete and document a thorough home-safety inspection during patient visits.
Provide direct patient-care support and patient education at the direction of the assigned Provider, within the LPN scope of practice.
Complete minimally-invasive patient screenings and point-of-care testing (POCT), and clearly explain POCT to geriatric patients.
Subject to applicable state laws and restrictions, training, and company protocols, safely and competently perform venipuncture and capillary blood collection for geriatric patients in home settings.
Subject to applicable state laws and restrictions, training, and company protocols, safely and competently perform intravenous therapy.
Support the Comprehensive Initial Visits, Follow-up Visits, and Urgent Visits.
Complete drop-in visits for the unengaged and disengaged patients and support open HEDIS .
Conduct check-in visits/calls to our lower acuity patients, enhancing our “call us first” model.
Escalate patient clinical concerns to the APP, Community Operations Director (COD), or Community Medical Director (CMD).
Develop rapport and deliver exceptional, compassionate in-home service; provide positive customer service and treat all patients and staff with respect.
Act as a community resource for the patient and work to engage patients who are not currently engaged in care.
Schedule patient appointments with the WellBe team and coordinate specialist appointments and diagnostic tests.
Answer patients’ clinical questions strictly within the boundaries of the SOP.
Explain WellBe processes and the care journey.
Review patient-care interventions and assess patient needs for transitions of care, end-of-life discussions, palliative-care interventions, and medication adherence.
Support the APP in ongoing panel management and quality-of-care efforts; utilize HEDIS tracking tools to meet and improve HEDIS / STARS performance and close gaps, including medication adherence.
Contribute complete, accurate, and timely data to patients’ records and ensure all required clinical and non-clinical documentation is in the EMR; complete and submit all documentation daily.
Collaborate with the interdisciplinary team and participate in regularly scheduled team and Interdisciplinary Team (IDT) meetings, providing additional information on patient and family interactions.
Build relationships with local community providers and caregivers to maintain WellBe’s presence and reputation in local markets.
Attend all required trainings, including equipment / device training; complete ongoing education as additional skills and protocols are added.
Operate and drive their vehicle while conducting Company business in a safe and professional manner, always exercising due regard for self and other motorists.
Practice the WellBe mission: to help our patients lead healthier, meaningful lives by delivering the most Complete Care.
Maintain all required licensure and certifications, and supply valid copies of all certifications and driver’s license prior to their expiration dates, including a copy of the driver’s license for the annual MVR pull.
Other tasks needed to accomplish the team’s objectives and goals.