This position works for Crouse Medical Practice, a multispecialty physician practice with several locations to serve healthcare needs in the Syracuse, NY community!

JOB SUMMARY:

The LPN Population Health Support Specialist works as an integral part of an interdisciplinary team to gather information in support of provider, medical record documentation, upcoming appointment, and external sources for the non-provider portions of preventive wellness services for the identified patient population. This role will demonstrate compassion, collaboration, communication, and appropriate judgment in patient care. Assist in maintaining compliance with quality assurance standards and engage and support patients to ensure they feel heard, respected, and involved in their care. This is a remote position; however, the Specialist must live in Central New York.

RESPONSIBILITIES:

• Provides clinical guidance, education, and support to patients in need of preventive, chronic care, and transitional care services; specifically assisting those patients with multiple co-morbidities and complex health status in order to improve health outcomes.

• Review of provider schedules/spreadsheets/hospital discharge lists and identify patients appropriate for annual wellness visits and transitional care visits.
• Schedule patient visits within the established time frames.
• Conduct telephonic outreach to certain patient populations with chronic conditions, behavioral health issues and/or co-morbidities to administer pre-visit self-assessment questionnaire within established time frames.
• Confirm receipt of discharge, medical and social history of patients.
• Review medication information for reconciliation.
• Review information on potential (risk factors) for depression of patients.
• Review information on patient’s functional ability and level of safety.
• Responds to questions raised during patient outreach calls and troubleshoots/intervene/ refer as needed.
• Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the healthcare team.
• Update patient’s medical records in EMR by uploading health maintenance documents from external sources (immunizations, screenings, consultations etc.).
• Communicate appropriately with practice staff/providers as necessary.
• Ability to move through multiple management systems simultaneously.
• Complete appropriate pre-visit form and patient tracking spreadsheet.
• Make appropriate referrals to other services within the department (Chronic care management, behavioral health).
• Other duties as assigned.

MISSION/VISION/VALUES:

An employee of Crouse Medical Practice is part of a team that supports our mission; to promote the best in patient care and community health.

We provide this care through our vision which includes: (1) being committed to excellence in all areas of our organization;(2) building a dynamic work environment where all are valued, respected, and are provided the opportunity for personal and professional growth; (3) strengthening the relationships among our practices and other healthcare providers to enhance an integrated healthcare delivery system; (4) treating patients, families and colleagues with respect, dignity, courtesy and compassion; (5) operating in a fiscally responsible manner that allows us to provide the best in patient care and technology; and (6) enhancing access through expanded services designed to meet the ever growing needs of our patients

All employees are required to live and demonstrate in their daily responsibilities our organizational values of:

• Integrity
• Mutual Respect & Teamwork
• Compassion
• Service Excellence

STRATEGIC INITIATIVES:

1. 1. PEOPLE
   2. QUALITY
   3. GROWTH
   4. STEWARDSHIP
   5. SYSTEM INTEGRATION

PATIENT CENTERED MEDICAL HOME (PCMH):

Crouse Medical Practice provides services through a team model that supports the patient centered medical home. Knowledge of the below PCMH elements as they relate to an employee’s specific responsibilities contained in this description is essential.

Engage patients, families and their caregivers in understanding, establishing and monitoring patient self-management care plans in a manner that is culturally and linguistically appropriate to the patient, family and caregiver.

Apply the principles of comprehensive, community –based, patient-centered, developmentally appropriate, and culturally and linguistically sensitive care coordination services.

Coordinate the patient’s care by facilitating patient, family or caregiver access to medical home providers, employees and resources as needed by the patient.

Complete health risk assessments as a foundation of developing individualized care plans and outcomes goals for patients, families and caregivers. Document each patient’s individualized care plan and care coordination in the Practice’s EMR. Conduct and document assessments of patient needs and resources for effective self-care management.

Develop and maintain relationships among patients, families and caregivers, and the patient’s care team that support patients’ access to the medical home.

Act as the primary contact point, advocate and source of information for patients, and the community partners who help treat them.

Research, find and link patients to resources, services and support mechanisms for their care plans and self-care needs.

Provide timely communication with patients, make inquiries, execute follow up actions and help to integrate information into the care plan.

Assist the care team by helping to measure quality and identify, refine and implement practice improvements that support the medical home, and assist in performance evaluation and quality improvement.

Seek continuing professional growth through attendance at workshops, professional in-services and individual research and reading, to include communication skills.

ATTENDANCE/PUNCTUALITY:

• Schedules time off in advance.
• Follows company call-in procedures.
• Begins work on time.
• Keeps absences within guidelines.

CONTINUOUS LEARNING:

• Demonstrates accountability for own competence and growth and seeks out appropriate resources to enhance competency and improve performance.
• Keep personal in-service record up to date.
• Attends required meetings as requested.
• Annual review of office policies and procedures, ensuring compliance regulation standards, including but not limited to those aligned with PPC-PCMH accreditation.

QUALITY PERFORMANCE IMPROVEMENT:

Participates as requested in quality performance projects to improve quality of the company, including those which align with the company’s dedicated efforts to ensure further development of our company as a regionally and nationally recognized patient centered medical home.

ACCESS, USE and DISCLOSURE OF PATIENT INFORMATION:

Position requires access to patient Protected Health Information (PHI) and individually Identifiable Health Information (IIHI) within the job responsibilities listed above. Employee is advised that inadvertent and/or intentional disclosure of this information violates Federal Law and can result in termination and/or fines.

TYPICAL WORKING CONDITIONS & PHYSICAL DEMANDS:

Some exposure to communicable diseases or toxic substances, ionizing radiation, therapeutic preparations and other conditions common to a health care environment.

Requires full range of motion including handling and lifting, manual and finger dexterity and eye-hand coordination. Requires standing and walking for extensive periods of time. Occasionally lifts, carries and pushes items weighing up to 50 pounds. Requires corrected vision and hearing to normal range. Requires working under stressful conditions or working irregular hours. Requires exposure to communicable diseases or body fluids.

MINIMUM REQUIREMENTS:

• EDUCATION/CERTIFICATION/LICENSURE:
  • Licensed Practical Nurse with current NY Licensure.
• EXPERIENCE:
  • Two years minimum clinical experience, and/or
  • Two years minimum experience in an Outreach setting, Managed Care, Case Management, Ambulatory clinic setting, or related field.
  • Working knowledge of Microsoft Office applications such as Excel and Word.
  • Familiarity with Medent or other EMR systems, HealtheConnections and RingCentral or similar platform (Zoom, Microsoft Teams).
• SKILLS/PROFICIENCIES:
  • Proficient computer and typing skills.
  • Excellent verbal and written communication skills with the ability to clearly communicate test results and document legibly.
  • Interpersonal skills necessary to interact effectively with patients, team members, and physicians and to maintain team-oriented relationships with senior management, managers and staff.
  • Ability to work efficiently with minimal supervision while exercising attention to details and independent judgment within stated guidelines.
  • Ability to maintain high customer service standards.
  • Proficient computer skills and the ability to learn and effectively utilize department specific software systems.
  • Ability to effectively perform or learn technical skills to perform essential functions within allocated time frame.
  • Ability to work a flexible schedule as part of a team.

Pay Range: $21.00-$30.00 DOE