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Population Health Nurse (LPN)
Overview:
Exciting opportunity to join our clinical team as a full-time Licensed Practical Nurse (LPN) in our Population Health Department within a Federally Qualified Health Center (FQHC).
ReGenesis Health Care (RHC) is committed to improving quality of life by providing patient-centered affordable and accessible health care in partnership with communities we serve. To learn more, go to www.myrhc.org.
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The Population Health Nurse will be responsible for following-up with patients who have been admitted to and discharged from hospitals or emergency departments, and scheduling patients for timely follow-up appointments with the assigned ReGenesis Health Care (RHC) Provider. The Population Health Nurse will also work with the Population Health team on the implementation, monitoring, and completion of Population Health initiatives at RHC, most notably in those areas pertaining to HEDIS measures, ER Utilization Review, and Patient Care Coordination. They will be expected to provide direct patient in-reach and outreach. This position is full-time. This position will be part of a Care Management Team and will provide case management services to a targeted SC Medicaid, Medicare, Commercial Insurance, and Self-pay patient populations in Spartanburg, and Cherokee, and Union counties.
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Excellent pay up to $27.00 per hour with excellent full-time benefits.
Duties and Responsibilities:
- Contact patients within 48-72 hours of discharge from the hospital or emergency department.
- Conduct thorough assessment of patients’ needs, including medication reconciliation, follow-up appointments, and health-related social needs.
- Coordinate with primary care providers, specialists, and other healthcare providers to ensure a seamless transition of care.
- Access and systematically use data from multiple sources such as patient medical records, Insurance plan rosters, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.
- Research all aspects of patient electronic medical records to evaluate utilization of care and patient account information.
- Manage and monitor lists of patients for gaps in care, ER utilization, and interventions.
- Provide front-line support for HEDIS gaps closures and other utilization initiatives. which include, but is not limited to:
- Patient in-reach and outreach via phone calls, mailings, and face-to-face visits
- Data collection and entry
- Embed in physician practices (travel throughout site locations and offsite, as needed) to provide patient in-reach and assist other clinical staff with patient education, and gap closures at the point of service.
- Expand the interdisciplinary team by assisting in care team “huddles.”
- Communicate and coordinate with all providers and members of the care team as needed to ensure continuity of care.
- Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence-based care.
- Support disease management programs, including scheduling, data entry, report generation and distribution.
- Research all aspects of patient electronic medical records to evaluate utilization of care and patient account information.
- Efficiently schedule, reschedule, or cancel patient appointments for designated outpatient services in the RHC central scheduling system as it relates to HEDIS gaps and care coordination initiatives.
- Interview and register patients who are eligible for RHC’s care management programs. Assess patient need for outside case management and provide direct referrals for internal and external support.
- Obtain accurate demographics when scheduling appointments related to RHC’s care initiatives.
- Create and maintain reports for tracking metrics regarding success of project productivity.
- Establish and maintain open and professional demeanor, and communication with other departments, and physicians whose services could be impacted by RHC’s care initiatives.
Benefits and Perks:
- Medical, dental, vision, and life insurance (Eligible first of month following hire date)
- 18 paid days off.
- No holidays, weekends or call!
- 9 1/2 paid company holidays, including your birthday.
- $2,000 sign on bonus paid after 90 days.
- 401K with Company Match.
- Agency wide "Quarterly Incentives" (Eligible after 90 days).
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