Job Description

Job Description

Collaborate with RN Care Coordinator to manage a patient panel of up to 250. Perform periodic holistic care management based on initial assessment and goals as outlined by RN Care Coordinator. Provide education regarding disease management based on current best practice standards. Identify patients who may need closer follow up and escalate care to RN Care Coordinator as appropriate for re-evaluation and triage. Knowledge of current federal, state, and local programs as well as their eligibility requirements and application process in order to pro-actively connect patients with appropriate resources. Implement care management plan and goals established by RN Care Coordinator and mutually agreed upon by patient/family. Utilize motivational interviewing techniques and assist patient in meeting action-oriented goals and objectives. Evaluate effectiveness of plan in meeting established care goals. Collaborate with RN Care Coordinator in instances where goals may need to be revised. Interacts professionally with patient/family to achieve maximum levels of wellness and independence. Perform weekly follow up calls for patients recently discharged from the hospital who are considered high risk for readmission until patient has been discharged for 30 days. Ensure that the patient has attended follow up appointments as scheduled and is adherent to medications. Provide patient with education regarding hospital diagnosis. Identify patients who have had a change in condition and escalate care to RN Care Coordinator for further evaluation/triage. Serve as liaison to providers, patients and families for coordination of services. Maintains EMR databases on care managed population. Maintain accurate and timely documentation and billing based on care plan initiated by RN Care Coordinator. Identify patients who have had a change in condition and escalate care to RN Care Coordinator for review of care plan. Review utilization and quality reports routinely, scan for gaps in care and identify patients needing the additional support of care management. Participates in regular team meetings. Participates in departmental and organizational committees as applicable. Participates in the orientation of new personnel. Precepts and acts as a mentor to peers. Promotes collaborative teamwork. Meet with RN Care Coordinator team lead and Manager Population Health Outpatient Care Coordinator on a regular basis to provide patient updates, identify issues, and develop strategies for resolution. Performs all duties and responsibilities in accordance with basic principles and guidelines of professional nursing. Ensures documentation meets current standards and policies. Attend conferences, workshops, and complete continuing education as assigned.

Education: High School Diploma required. Certification & Licensures: LPN License required. Based on primary state of residency and in accordance with current Virginia Board of Nursing Regulations, must be licensed or eligible to practice pending licensure as a Licensed Practical Nurse in the Commonwealth of Virginia and/or West Virginia (as applicable depending upon geographical area assigned) with either a: Multi-State License, under the Nurse Licensure Compact required. BLS Certification (Basic Life Support) - American Heart 'Healthcare Provider' (HCP) - AHA approved required. New hires must have American Heart Association (AHA) appropriate certification prior to completion of orientation. Qualifications: Experience in an outpatient setting as an advocate role for a community health services position preferred. Basic knowledge of medical terminology preferred. Ability to interact with other professionals as part of a multidisciplinary team. Experience with word processing package such as Microsoft Office desirable. Valid driver's license based on primary state of residency. Ability to travel to meet with clients/attend business functions/trainings/meetings at all VH work sites required. Knowledgeable in the cognitive, physical, emotional, and chronological stages of human growth and development required. Communicates effectively and works cooperatively with others required. Knowledge of funding, resources, clinical standards and outcomes for population required. FLSA Classification: Exempt. Physical Demands: 20 A Nursing, Certified Nursing Assistants (CNA), Patient Care Tech.

Benefits: At Valley Health, we believe everyone is a caregiver, and our goal is to create an environment where our caregivers thrive physically, financially, and emotionally. In addition to a competitive salary, our most popular benefits for full-time employees include: A Zero-Deductible Health Plan, Dental and vision insurance, Generous Paid Time Off, Tuition Assistance, Retirement Savings Match, A Robust Employee Assistance Program to help with many aspects of emotional wellbeing, Membership to Healthy U: An Incentive-Based Wellness Program. Valley Health also offers a health savings account & flexible spending account for childcare, life insurance, short-term and long-term disability, and professional development. In addition, several perks come with working for the largest employer in the region, such as discounts to on-campus dining, and more.

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