Community Health Nurse Population Health

Location: Mamou

The Population Health Nurse will promote effective partnerships between patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines to coordinate care for patients with chronic disease and effectively manage care transitions to facilitate a "shared goal model". The Population Health Nurse will partner with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness.

ESSENTIAL DUTIES & RESPONSIBILITIES:

* Manages the primary clinics' Medicare population

* Identifies eligibility for CCM and RPM

* Performs pre-assessment evaluation

* Completes and tracks annual wellness visits

* Follow up with preventative screenings

* Coordinates with clinics providers and staff

* Provides effective clinical health coaching to assist the patients with self-management of their chronic disease and life-style changes to mitigate health risks.

* Completes data collection, analysis and reports in a timely manner

* Assists with chart audits and data submission for various payers related to quality incentive programs.

* Train/educates new clinic LPN's and M.A.'s on Vaccine for Children Program (VFC)

* Assists Director of Clinical Operation with special projects

* Some travel between Savoy Medical Clinics will be required

Requirements

• Current LPN licensure in State of Louisiana.

• Current BCLS certification.

• Physician office experience (preferred) and/ or the demonstrated ability to adapt to situations.