Job Description

General Summary

Provides safe, therapeutic and efficient care and services to patients. Supports the care team by functioning as a health coach for disease prevention and early screening, testing and treatment. Helps patients manage their chronic diseases. Assists in the care of patients, and instructs patients and their families in appropriate care, as directed by their provider. Functions as a member of the care team to assist in the planning and implementation of patient care based upon sound clinical preparation, knowledge, skills and experience. Provides practice and guidance to the patient/caregiver for effective care transitions, improved self-management skills and enhanced patient-practitioner communication. Care is provided in accordance with the provisions of Practical Nurse Licensure with the Pennsylvania State Board of Nursing.

Duties and Responsibilities

Essential Functions:

• Provides support to patients of the practice for clinical outcome management, healthy lifestyle information, via appointment coordination and navigation of the health system.
• Completes transitions of care calls for moderate risk patients discharged from Hospital/ED and thoroughly documents. Arranges follow-up services and identifies issues and concerns to appropriate staff as needed.
• Communicates and shares information with providers and care team members on issues and concerns such as transition of care between hospital, skilled nursing facility, rehab and home care. Supports the care team by functioning as a health coach for disease prevention, early screening and testing and treatment and for helping patients manage chronic diseases.
• Generates/review payer lists of patients in order to proactively manage patients and families with service needs for prevention or chronic conditions.
• Supports the care team by functioning as a coach for disease prevention, early screening and testing and treatment and for helping patients manage chronic diseases.
• For patient populations where WellSpan is at financial risk, provides direct care management interventions by completing the Shared Care Plan. Interventions include: assisting patients with goal setting, creating action plans to manage their health, addressing barriers to patient adherence to treatment plan, assisting patients with referrals utilizing wellness and self-management programs.
• Assists patients with instruction and health literacy through teach back of any new medications, instructions and referrals. Monitors outcomes while following up on interventions identified in the care plan within scope of practice. Provides health care information materials and reviews with patient and or family members as directed by providers.
• Maintains the patient’s records to ensure an accuracy of the patient’s medical treatment. Documents in the patient record under the direction and supervision of the care provider.
• Uses Motivational Interviewing techniques to engage patients in self-management skills.
• Ensures practice meets the standards to bill for chronic coaching services.
• Addresses and mitigates patient social determinants of health needs that could negatively impact care plan follow through.

Common Expectations:

• Demonstrates a commitment to safety and quality by following established policies and procedures, reporting concerns, and participating in efforts to reduce risk and improve care.
• Provides exceptional service to patients, providers, coworkers, and visitors by fostering teamwork, maintaining professionalism, and supporting a respectful, clean, and efficient work environment.
• Engages in professional development and contributes to department goals by attending required meetings, using technology effectively, and identifying opportunities for improvement.

Qualifications

Minimum Education:

• Certificate Program Post High School Vocational/Specialized Training Required

Work Experience:

• 1 year Healthcare experience. Required

Licenses:

• Licensed Practical Nurse Upon Hire Required or
• Licensed Practical Nurse Multi State License Upon Hire Required or
• Basic Life Support Upon Hire Required

Courses and Training:

• Completes all required education programs and competency testing needed to perform at an advanced level. Upon Hire Required

Knowledge, Skills, and Abilities:

• Proficient communication skills including SBAR technique.
• Ability to effectively present clinical information to the care team.
• Proficient in navigating and entering information into an electronic health record.
• Models team work.
• Self-motivated and dependable.
• Able to work independently.

Benefits Offered:

• Comprehensive health benefits
• Retirement savings plan
• Paid time off (PTO)
• Education assistance
• Financial education and support, including DailyPay
• Expanded Paid Parental Leave

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)