A Nurse Health Advisor is a key member of the primary care team, serving as a clinical health advocate who works with a targeted group of patients to support the primary care team in such a way as to ensure physicians are operating at the top of their licenses while ensuring patients are receiving the preventive care they need. He/she will help individual patients resolve ambivalence and develop behavioral changes to improve health outcomes such as medication adherence and chronic disease management. He/she works toward improving overall quality metrics ratings by bringing members into compliance and closing gaps in care. The ideal candidate must be friendly, approachable and self-confident. He/she must have excellent verbal communication skills, an open-minded perspective to working with diverse populations, problem-solving skills, and a strong desire to help people as well as shape the future of healthcare. Talent Pool: Nursing |
Job Level: Licensed Practical Nurses
Campus: Enterprise Wide Priority Roles
| Annual Medicare Wellness Visits (AMW): Identify patients who are eligible for a Medicare Annual Wellness Visit and educate these patients on the importance of these visits. Conduct AWVs. Refer patients to physician as appropriate. Completes and documents information in Electronic Medical Record (EMR). -------------------------------------------------- Attends required meetings and participates in committees as requested. Participates in professional development activities and maintains professional affiliations. Functions as a member of the interdisciplinary team, providing updates on trends and outcomes to the provider. -------------------------------------------------- Chronic Care Management (CCM): Identify patients who are eligible for CCM. Educate patients on the value of the CCM call and obtains patient consent. Assesses patient's background, resources and health issues and co-creates care plans around creating healthier lifestyles. Educates patient about health improvement and provides coaching for changing behaviors through strategies such as motivational interviewing and creating accountability. Develops plans, strategies and goals in partnership with the patient and helps the patient track adherence to treatment goals. Participate in face to face (F2F) visit with provider and patient. Help develop, in conjunction with providers, the patient's specific care plan. Conduct CCM calls. Data entry of assessments, care plans, and goals into EMR. -------------------------------------------------- Gaps in Care: Provider Panel Management. Understands system quality improvement expectations (MU, ACO, and PCMH) and works to align the provider's panel with those metrics. Reviews and interprets provider level data on QI activities including evaluation of the effectiveness of interventions, adjusting plans as needed and presenting outcomes to provider and practice manager. Review and identify patients in need of screenings, tests, vaccines, and immunizations. Work with Care Guide and schedulers to schedule appointments for patients. Conduct visits to provide necessary screenings, tests, vaccines, and immunizations. Document appropriately in the EMR. -------------------------------------------------- Medication List Review and Verification: Collect and review pharmacy reports to determine whether patient is adhering to medication regimen. Work with patient to identify and resolve any barriers to their medication adherence. Reach out to poly-pharmacy patients 48 hours after visit to review medication regimen and ensure they received their medications. Review and verify list of medications and compare to EMR data, make changes and necessary. -------------------------------------------------- Pre-Visit Planning: Identify patients who have an upcoming appointment, identifies gaps in care and conducts pre-visit planning calls with these patients. Initiate standing orders as appropriate. -------------------------------------------------- Transitions of Care: Identifies Triad HealthCare Network (THN) and other at-risk patient populations who have been admitted to the hospital or ER and connects with those patients within 2 days in order to answer any questions and schedule a follow-up visit within 7 and 14 days of discharge. Performs follow-up visit for certain types of cases. -------------------------------------------------- |
| EDUCATION: |
| Required: Graduate of a Licensed Practical Nursing program |
| EXPERIENCE: |
| Required: 3-5 years? experience as an LPN. Experience providing patient education and/or health coaching preferred. An equivalent combination of education and experience may be considered. |
| LICENSURE/CERTIFICATION/REGISTRY/LISTING: |
| REQUIRED LPN License Drivers License | Valid Drivers License PREFERRED Preferred: Certified Health Education Specialist or Certified Health Coach |
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