Population Health LPN, Full Time, DIO Miramar FL: CORP - Pop Health So (PHSO)
Full Time
Miramar, FL 33025
Posted
Job description
Summary:
Under the direct supervision of the Population Health Management Nurse II and Population Health Management leadership, the Population Health Nurse I (PHN) is an integral member of a multidisciplinary care team. The PHN serves as a liaison between the Memorial Healthcare System (MHS), Memorial Health Network (MHN), Memorial Physician Group (MPG), community providers, healthcare organizations, and patient. The PHN follows nursing processes that facilitate care coordination and close monitoring of specially defined low to medium risk patient populations. The PHN fosters a multidisciplinary team based approach ensuring continuity of care extends beyond the acute-care boundaries.
Under the direct supervision of the Population Health Management Nurse II and Population Health Management leadership, the Population Health Nurse I (PHN) is an integral member of a multidisciplinary care team. The PHN serves as a liaison between the Memorial Healthcare System (MHS), Memorial Health Network (MHN), Memorial Physician Group (MPG), community providers, healthcare organizations, and patient. The PHN follows nursing processes that facilitate care coordination and close monitoring of specially defined low to medium risk patient populations. The PHN fosters a multidisciplinary team based approach ensuring continuity of care extends beyond the acute-care boundaries.
Detailed responsibilities:
- Conducts initial intake, assessment, identifies and manages health and safety risks including assessment of social determinants of health, functional status, health risk assessment, and medication clarification and education. Discusses assessment with Population Health Nurse II for co-signature on assessment. As appropriate, discusses patients eligibility for population health management services or disease management programs. Assesses patient/caregiver capacity and willingness to participate in such programs.
- Follows the patient-family centered care plan developed by the Population Health Nurse II. Initiates patient conference with Population Health Nurse II for modifications to care plan. Under the guidance of the Population Health Nurse II provides telephonic care/case management services including but not limited to health risk assessment, medication clarification, clinical-decision making, remote patient monitoring, and disease management for low to moderate risk patient population. Applies evidence-based clinical guidelines and protocols to promote high quality healthcare delivery.
- Performs concurrent medical record review using specific indicators and criteria established by the Population Health Nurse II. Monitors the quality, frequency and appropriateness of healthcare delivery by post-acute providers and reports variations of plan of care, health status, or psychosocial issues to PCP and appropriate members of the care team. Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in coordination of care across the healthcare continuum.
- Serves in an expanded healthcare role to collaborate with interprofessional colleagues, and patients/families to ensure care coordination that is not fragmented to reduce readmissions and/or complications for a defined low to medium risk patient population.
- Supports, participates, and coordinates in preparation and completion of quality audits, quality reporting and regulatory reviews. Collaborates closely with the Population Health Management leadership and Population Health Service Organization Business Intelligence teams to review and provide input on utilization trends.
- Responsible for interpreting and responding appropriately to automated alerts and notifications in remote patient monitoring.
Competencies and skills:
Essential:
- STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
- CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
- ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
- RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.
- ANALYSIS AND DECISION MAKING: Uses decision making processes and tools to analyze situations and make effective decisions.
- TEAM WORK: Contributes to fullest potential to achieve team goals.
- PATIENT AND FAMILY CENTERED CARE: "Provides Patient and Family Centered Care to patients, families, visitors and internal customers"
- CLINICAL POLICIES AND STANDARDS: Applies knowledge of clinical standards, policies, and procedures relevant to function and organization.
- DISEASE MANAGEMENT: Applies knowledge of practices and interventions for specific populations with specific conditions.
Education:
Essential:
Essential:
- Accredited Program
Education specialization:
Essential:
Essential:
- Licensed Practical Nurse
Credentials:
Essential:
Essential:
- Licensed Practical Nurse - Florida
Education equivalent experience:
Essential:
- •
Other information:
Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships. The incumbent must be able to take appropriate action when required.
Required Work Experience: +3 years of healthcare experienceExcellent written and oral skills, with the ability to engage, inspire, build credibility and trust with peers and patients Collaborative working style with the ability to work across different teams, areas of expertise, and adapt to various environments and clienteleHighly organized and self-motivated individual with ability to adapt to various assignments and ability to work autonomously
Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships. The incumbent must be able to take appropriate action when required.
Required Work Experience: +3 years of healthcare experienceExcellent written and oral skills, with the ability to engage, inspire, build credibility and trust with peers and patients Collaborative working style with the ability to work across different teams, areas of expertise, and adapt to various environments and clienteleHighly organized and self-motivated individual with ability to adapt to various assignments and ability to work autonomously
Working conditions:
Essential:
Essential:
- Bending and Stooping 60.00%
- Keyboard Entry 80.00%
- Lifting or Carrying 0 - 25 lbs Non-Patient 60.00%
- Pushing or Pulling 0 - 25 lbs Non-Patient 60.00%
- Pushing or Pulling 26 - 75 lbs Non-Patient 60.00%
- Pushing or Pulling > 75 lbs Non-Patient 60.00%
- Reaching 60.00%
- Repetitive Movement Hand/Arm 80.00%
- Sitting 80.00%
- Standing 80.00%
- Walking 80.00%
- Audible Speech 80.00%
- Hearing Acuity 80.00%
- Depth Perception 80.00%
- Distinguish Color 80.00%
- Seeing - Far 80.00%
- Seeing - Near 80.00%
- Computer Monitor 80.00%
- Wet or Slippery Surfaces 40.00%
Disclaimer:
This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.
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