Job Description

Under the general supervision of the Manager of Population Health & Care Coordination, is responsible for coordinating clinical care; educating; advocating; and assisting as the health navigator for patients in the Huggins Hospital Medical Practices. In addition, this position is responsible for assistance with data collection, analysis and reporting.

Patient Centered Care:

• Participates in Patient-Centered team meetings
• Participates in data collections, health outcomes reporting, clinical audits, and programmatic evaluation related to Patient-Centered Care Coordination initiatives

Direct Patient Care:

• Facilitates health and disease management education
• Supports patient self-management of disease and behavior modification interventions.
• Provides comprehensive preventative wellness exams 3: Weight

Care Coordination:

• Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits
• In collaboration with PCP, manages high risk patient care, including management of patients with multiple comorbidities or those at high risk for readmission to a hospital setting
• Promotes clear communication amongst a care team and with treating clinicians by ensuring awareness regarding patient care plans

Population Health & Quality Improvement:

• Works with the Population Health Manager and IT on care opportunity reports to identify and address preventative care
• Works to maximize opportunities for quality incentive payments from governmental and private payers related to population health and chronic care management
• Provides data analytics and reporting for population health and disease management.
• Participates in quality review, performance improvement, and medical practice patient satisfaction improvement initiatives
  

Organizational Expectations:

• Attendance: Attendance is an essential job function; employee comes to work daily, on time, and completes scheduled shift
• HIPAA: facilitates to maintain patient confidentiality
• Internal communication: contributes to positive team performance and a culture of service excellence through effective communication, active listening, and respect
• Interpersonal relationships: maintains appropriate interpersonal relationships with staff, patients, and visitors at all times. Works as a team member with other departments.
• Safety: Practices workplace safety daily

Employee Engagement:

• Actively participates in all hospital Service Excellence initiatives and trainings
• Attends and participates in a minimum of 50% department staff meetings and signs off on review of 100% department staff meeting minutes
• Completes all required annual education on or before the due date

Knowledge Skills and Abilities: Individuals must possess these knowledge, skills, and abilities or be able to explain and demonstrate that they can perform the primary functions of the job, with or without a reasonable accommodation, using some combination of skills and abilities and possess the necessary physical requirements, with or without a reasonable accommodation, to safely perform the essential functions of the job.

• Minimal physical effort required with occasional light lifting to a maximum of 25 pounds; stooping; and pick, pinch, type, or otherwise work primarily with fingers
• Ability to effectively manage considerable mental stress
• Ability to express or exchange ideas by means of the spoken word
• Ability to receive detailed information through oral communication
• Ability to communicate effectively with co-workers and convey information in a clear, concise and accurate manner
• Familiarity with computer and other business machines
  

Qualifications:

Completion of RN or LPN program
One year office experience preferred

Active NH RN or LPN License
BLS Required