Population Health Nurse - L.P.N. in Clinton, Missouri at Golden Valley Memorial Hospital

Population Health Nurse - L.P.N.

Summary: The Population Health Nurse - LPN works with primary care providers and their staff to ensure patient care needs are met and provides patient and/or caregiver education on disease processes, medications, and other treatment prescribed/ordered by the provider. Performs transitional care management, self-care management education, medication reconciliation, and care planning for patients identified as needing this level of care. Current Missouri LPN license and Basic Life Support (BLS) certification required.

Job Responsibilities:
1) Documents accurately and timely according to Rural Health Clinic and Joint Commission standards. Completing, updating, and reviewing patients' health summaries and clinical information.

2) Work collaboratively with the provider and care team to manage high-risk patients with multiple comorbidities that are complex or poorly controlled, patients at high risk of readmission to acute care, and patients who require more intensive care coordination, as identified by provider. Participate with a care team in individualized care planning and self-management goals with patients.

3) Review daily provider huddle reports identifying the patient's needs for labs, procedures, referrals, tests, and assist with ordering or scheduling as needed. Perform daily care team rounding after reviewing huddle reports to share patient needs with the care team.

4) Assist providers in identifying patients at moderate to high risk of readmission following an acute admission to hospital and initiate Transitional Care Management services with patients. Requires close collaboration and effective communication with providers and care teams to ensure all elements of the TCM service are met and documented accurately.

5) Provide timely, accurate communication to providers, patients, internal and external customers to ensure safe, quality patient care.

6) Complete tasks on the work list daily and provide necessary follow-up and communication with care team, providers, and patients.

7) Assist with maintaining Rural Health Clinic and Joint Commission compliance; documents accurately and timely according to Rural Health and Joint Commission standards; completing, updating, and reviewing patients' health summaries and clinical information.

8) Participate in quality improvement initiatives as requested.

9) Ability to react to changing productivity and handle other essential tasks as assigned by the supervisor.