LPN | Population Health Nurse
Hillsdale Hospital
- Location
- Hillsdale, Michigan, United States
- Job type
- Full-time
Required skills
- EMR
- Health IT systems
- Electronic Health Records
About the role
Work Schedule:
0800 to 16:30 Monday through Friday at Hillsdale Hospital clinics
Benefits
- Insurance: medical, prescription, dental, vision, life, disability
- Paid Time Off: vacation, holidays
- Retirement: 403(b) with match
- Education assistance & continuing education; many courses offered on-site at the hospital
Qualifications:
- Current Michigan licensure as an LPN
- Previous experience in caring for chronic disease patients required
- Prefer experience in clinical or community health, care coordination, case management, home health or behavioral health
- Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
- Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers if needed
- Must be proficient in communication and computer technologies (email, cell phone, etc.)
- Previous experience with health IT systems, ERMs and data reports
Responsibilities:
- Provides a coordinated, strategic approach to detect early and manage effectively the chronically and/or mentally fragile patient population.
- Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care.
- Assesses patient and family’s unmet health and social needs
- Provides effective communications to improve health literacy for patients/families
- Coaches patients/families towards successful self-management of their chronic disease
- Acts as liaison between PCP and Specialists on patient condition as needed between office visits
- Develops a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan
- Monitors patient adherence to plan of care and progress toward goals in a timely fashion, and facilitates changes as needed
- Creates ongoing processes for patients/families to determine and request the level of care coordination support they desire
- Promotes healthy behaviors in all populations and ensures navigation assistance with community resources
- Assists in outreach to patients made after they have been seen in ED or inpatient stay as necessary.
- Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator)
- Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
- Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
- Enrolls patient in Medicaid and assists with other community resource referrals when applicable.
- Ensures effective tracking of test results, medication management, and adherence to follow-up appointments
- Facilitates and attends meetings between patient, families, care team, payers, and community resources
- Ensures all VBR and MSSP metrics are met.
- Assists with VFC (Vaccines for Children) immunization programming at current Primary Care sites.
- Performs other duties as required or assigned.
Equal Opportunity Employer
About Hillsdale Hospital
Provides acute care and outpatient medical services to the community.
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