Shenandoah Community Health (SCH) is a Federally Qualified Health Center whose mission is to provide access to healthcare by reducing barriers to care. Our coordinated range of services includes primary care, women's health, behavioral health, oral health, HIV case management, pharmacy, lab, radiology, and a variety of support services. SCH also offers interpretation services for patients whose primary language is not English. Working at SCH is more than just a job, it is an opportunity to impact the lives of the people living in our community. Come join our team! To learn more about SCH, visit www.shencommhealth.com.

GENERAL DESCRIPTION OF DUTIES AND RESPONSIBILITIES: 

This position is primarily responsible for assisting and providing safe, consistent, and appropriate patient care within his or her scope of practice. He or she is an advocate for the patient. Ability to handle a diverse range of situations and responsibilities. Able to work in a multi-disciplinary team and have strong communication skills. This position focuses on quality improvement, data entry, and information retrieval as it relates to improving patient outcomes and Shenandoah Community Health financial viability. This person has strong computer skills, able to work independently. 

SPECIFIC DUTIES AND RESPONSIBILITIES:

•Performs with opportunity for independent judgement under general supervision. 

•Conducts telephone and face to face outreach to assigned patients to better their understanding of their health and the measures we are taking to manage their current health problems (chronic health problems, hospital discharges, etc.) as well as proactive measures to decrease future health risks. 

•Responsible for researching, analyzing, planning, implementing, and monitoring procedures and processes as related to patient outcomes, quality improvement, UDS measures, HEDIS Audits

•Uses ACO and other payer’s APPS/websites to assist in closing care gaps, performing TCM and ED/Hospital Discharge follow up, scheduling AWV’s and referring patients to ACO programs.

•Entering information into Electronic Medical Record (EHR). 

•Scheduling appointments, keeping medical record current, and working with insurance companies. Attends in person or virtual meetings with ACO, MCO’s and private insurers.

•Participates in weekly Care Coordination Meeting.

•To educate within scope of practice and problem solve with patients to identify and address specific goal(s) to support health and behavior/lifestyle change using a variety of assessment tools under the supervision/directions of the provider. 

•Provides appropriate interventions to optimize health and well-being. Interventions may include appropriate education, the coordination of community-based support services; labs; referrals; medical management; and scheduling appointments under the supervision/directions of the provider. 

•Performs effective pre–Adult Wellness Visit (AWV) assessments including but not limited to a Health Risk Assessment, patient/family medical history, current medications, allergies, depression, and functional activity screenings. 

•Collaborates with other members of the Primary Care Home Team (providers, health educators, nurses, social services, labs, specialists, hospitals, long term care facilities, etc.) to implement a plan of care for patients. 

•Works as a liaison between the physician, patient/and or family to improve quality and deficiency of care. 

•Demonstrates flexibility, open mindedness, and versatility in adjusting to changing environments and requirements as necessary. 

•Demonstrates courteous and cooperative behavior with patient’s families, co-workers, subordinates, supervisors, and other department staff. 

• Always maintains patient confidentiality and privacy according to SVMS policies and procedures; uses discretion when discussing patient matters. 

•Acts as role model for ancillary personnel. 

•Practices within the limits of the Nurse Practice Act and understands legal consequences of nursing action. 

•Other duties as assigned.

QUALIFICATIONS:

•Must be a graduate from a Licensed Practical Nursing Program with an active unencumbered LPN license in WV/VA.

•Must have the demonstrated ability to function effectively within a multi-disciplinary team. 

•Must have excellent skills in patient communication and education. 

•Must possess time management skills detailed oriented. 

•Must have strong computer skills, have worked with an Electronic Health Record 

•Strong understanding of Quality Measures, UDS, and Meaningful Use 

•Annual basic CPR certification is also required. 

•Previous experience working as an LPN is preferred.