Population Health Specialist

Description

SUMMARY:     Functions in conjunction with any medical provider including nurse practitioners, to assist in the provision of professional medical care and nursing support clinical duties in a clinical setting.  Nursing staff play a critical role in the delivery of quality medical care within the context of a federally qualified community health center.  Nursing staff will assist the AxessPointe Community Health Center, Inc. (API) Medical Providers as needed.

SUPERVISOR:  Director of Clinical Services and Quality Coordinator

DUTIES AND RESPONSIBILITIES:

• Assess and triage patient symptoms via phone using the nursing process and approved guidelines, to assist patient in obtaining the appropriate level of care and/or self-care advice maximizing office productivity. 
• Assist with comprehensive patient examinations, screenings, health education, and treatment of patients within the nurse’s scope of practice, using a systematic approach to history and physical appraisal of the patient, in person and over the phone.
•  Provides appropriate counseling and health education to patients, providing necessary literature and instructions for continuity of care, in person and over the phone.
• Able to accurately prepare, administer/perform, and record medications and / or procedures directed by medical provider including nurse practitioner.
• Develops and implements patient comprehensive management plans, records progress notes, and assists in provision of continuity of care.
• Educates patients on disease and compliance with medical regimen, prescribed therapeutic and drug regimens, plan of care, self-care management, preventative health guidelines and the post-acute continuum of care.
• Identifies & assists patient in accessing community resources. Evaluates effectiveness of developed plan of care; modifies and adjusts as appropriate to achieving desired process, utilization and clinical outcomes.
• Reviews potential denials and refers all medical necessity denials to Medical Director or Physician designee for final determination.
• Audit care management charts for completion
• Implement and support protocols around clinical problems such as following up on referrals, management of abnormal tests and bringing patients up to date with preventative screenings.
• Initiate, collect and execute population health outreach efforts.
• Assist in the creation and  delivery of presentations to various committees and boards about our programs.
• Documenting and maintaining patient records of services provided according to prescribed program standards, documents all nursing care consistent with professional standards utilizing the agency approved EMR system.
• Maintain a clean and orderly clinical atmosphere, performing routine monitoring and proper handling of equipment, medications, and supplies. 
• Serves as a clinical resource and go-to for Medical Assistant and other LPN staff, including staff training, education, and competencies as needed. 
• Maintains patient confidentiality at all times in accordance with HIPPA Regulations.
• Follows Health Department guidelines regarding communicable diseases.
• Other clinical duties and responsibilities as assigned by the Director of Clinical Services or Quality Coordinator

Requirements

MINIMUM QUALIFICATIONS:  

• Registered Nurse-ADN or BSN-Required
• Holds and maintains BLS certification through the American Heart Association  
• Minimum 2 years’ experience in a clinical environment. Experience in an FQHC environment strongly preferred.
• Knowledge MS Office, including Word, Excel, PowerPoint, and Outlook. Microsoft Access and Visio preferred. 
• Excellent organizational and interpersonal skills with exceptional professional work ethic. 
• Strong critical thinking and problem-solving skills. 

LICENSES OR CERTIFICATIONS REQUIRED:

• Unrestricted license to practice nursing in the state of Ohio
• Valid drivers license

COMPLIANCE: 

This position requires compliance with API's written standards, including its Compliance Program and Standards of Conduct and policies and procedures. Such compliance will be an element considered as part of the regular performance evaluation.

Failure to comply with API's Written Standards, which may include the failure to report any conduct or event that potentially violates legal or compliance requirements or API's Written Standards or, for managers and supervisors, fails to detect non-compliant conduct where reasonable efforts would have resulted in detection, will be met by the enforcement of disciplinary action, up to and including possible termination, in accordance with API's Compliance Program Policy and Procedure: Addressing Instances of Non-Compliance through Appropriate Disciplinary Actions.

PHYSICAL DEMANDS: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit, and use hands to finger handle or feel; to talk; or hear. The employee is frequently required to reach with hands and arms. The employee must occasionally stand, walk, climb or balance, stoop, kneel, crouch or crawl. The employee must be able to frequently lift up to 25 pounds. The employee may occasionally be required to lift 25 to 50 pounds; however, this is not essential; duties may be shifted to accommodate lifting restrictions.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to use close vision (clear vision at 20 inches or less). The employee will occasionally be working near moving mechanical parts, be exposed to outdoor weather conditions and exposed to a risk of electrical shock while running the copier, printer, other standard equipment and answering the telephone. The noise level in the work environment is low to moderate. Stress level can be high at times.

Note: This job description is not intended to be an exhaustive list of all duties, responsibilities or qualifications associated with the job.