Licensed Practical Nurse- Population Health

Population Health LPN

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.

Education:

Graduate of an accredited Practical Nurse program

Licensure:

Active LPN Ohio License

Experience:

2+ years of experience

Working knowledge of Microsoft Word, PowerPoint and Excel preferred

Experience with data visualization tools preferred

JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

1. Conduct outbound and inbound patient outreach via phone, portal, and other communication methods to support value-based care programs.

2. Identify and address care gaps related to preventive screenings, chronic conditions, and quality measures associated with Population Health.

3. Assess patients over the phone and escalate to physicians and APPs as appropriate.

4. Educate patients on recommended care, medication adherence, follow-up appointments, preventative care, and other healthcare specialties.

5. Document outreach activities, assessment, and interventions accurately in the EHR.

6. Performs post-discharge and transitional care follow-ups as assigned.

7. Support quality improvement initiatives and audits as needed.

8. Maintains accurate and risk-stratified patient panels for physicians and APPs, serving as an extension to the clinics.

9. Serve as a coordinator to align the needs of the patient with appropriate members of the care team.

10. Identify and assist the patient with support systems and community resources.

11. Collaborates with and acts as a resource for other departments, physicians, advanced practice providers, nurses, and other clinicians for population health data.

12. Performs other duties as assigned.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position in accordance with applicable law. A full job description is available upon request.

Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.