Population Health LPN

Current Employees:

(Determined by the knowledge, skills, and experience of the applicant.)

Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include:

*Supportive work culture

*Medical, Vision and Dental Coverage

*Retirement Plans, Health Savings Account, and Flexible Spending Account

*Instant pay is available for qualifying positions

*Paid Time Off Accrual Bank

*Opportunities for growth and advancement

*Tuition assistance/reimbursement

*Excellent pay differentials on qualifying positions

*Flexible scheduling

Essential Functions:

• Serve as a liaison between patients, families, and the interdisciplinary healthcare team to ensure that patient needs are met.
• Conduct health risk assessments and screenings, provide promote education and referrals as needed.
• Support population health initiatives aimed at improving the health of defined patient populations.
• Monitor and evaluate the effectiveness of population health interventions.
• Collect and analyze data to identify trends and areas for improvement in population health.
• Advocate for policies and practices that improve population health.
• Collaborate with community partners to support programs that address social determinants of health.
• Provide assistance and support in the development of population health programs.
• Works collaboratively with members of the care team to develop support a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the clinician.
• Post reminders to ensure that all co-morbidities are discussed and documented during AWV.
• Support competencies related to AWV screenings such as PHQ-9, TUG and Mini-Cog and assists in the training of the care team to perform these screenings.
• Support counseling services/resources within the practice to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety and advanced care planning.
• Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases; determine frequency for clinician visit and CCM encounters; maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
• In collaboration with the primary care physicians, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
• Participate in huddles with primary care physician and care team; identify scheduling opportunities, special needs for patients, patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments requiring rescheduling.
• Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, AWV scheduling, transition of care follow-up calls/visits, and CCM encounters.
• Collaborate with stakeholders to establish a method for assigning patients into a panel listing by clinician that is routinely utilized for scheduling purposes; utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers.
• Other duties as assigned.

Requires the ability to work assigned schedules and hours as determined by the department

Make a difference.  Every day.

Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.