Patient Care Advocate II (PCA II

The Patient Care Advocate II (LPN/LVN) is a licensed, field-based member of Well Be’s interdisciplinary geriatric care team who delivers white-glove, high-quality, in-home care to frail, poly-chronic, elderly Medicare Advantage patients in the comfort of their own homes. This role combines patient-advocacy, care-coordination, and quality (HEDIS) responsibilities with clinical and telehealth visit-facilitation responsibilities. Practicing within the LPN/LVN scope of practice and at the direction of the assigned Provider, the Patient Care Advocate II conducts in-person patient visits, facilitates in-home telehealth consultations with an APP or Physician, captures and documents clinical data, supports patient education, and serves as the local-market connector for patient support services across the Well Be platform.

The role models the Well Be mission and values, works closely with the provider and social-work teams, and functions as part of an integrated, interdisciplinary care team with no direct-report responsibility. The incumbent follows the rules and regulations of state and federal regulatory agencies and other certifying bodies for their region. Daily, local travel to meet patients and engage the community is an essential part of the role.

• Facilitate in-home telehealth visits between the Well Be APP or Physician and the patient, including initial patient assessments, urgent visits and ongoing follow-up visits as appropriate to patient need.
• Check and record health vitals - including weight, blood pressure, heart rate, lung sounds, and blood-sugar levels - and document health changes observed during the visit or reported by the patient.
• Complete and document a thorough home-safety inspection during patient visits.
• Provide direct patient-care support and patient education at the direction of the assigned Provider, within the LPN scope of practice.
• Complete minimally-invasive patient screenings and point-of-care testing (POCT), and clearly explain POCT to geriatric patients.
• Subject to applicable state laws and restrictions, training, and company protocols, safely and competently perform venipuncture and capillary blood collection for geriatric patients in home settings.
• Subject to applicable state laws and restrictions, training, and company protocols, safely and competently perform intravenous therapy.
• Support the Comprehensive Initial Visits, Follow-up Visits, and Urgent Visits. Complete drop-in visits for the unengaged and disengaged patients and support open HEDIS .
• Conduct check-in visits/calls to our lower acuity patients, enhancing our “call us first” model.
• Escalate patient clinical concerns to the APP, Community Operations Director (COD), or Community Medical Director (CMD).

• Develop rapport and deliver exceptional, compassionate in-home service; provide positive customer service and treat all patients and staff with respect.
• Act as a community resource for the patient and work to engage patients who are not currently engaged in care.
• Schedule patient appointments with the Well Be team and coordinate specialist appointments and diagnostic tests.
• Answer patients’ clinical questions strictly within the boundaries of the SOP.
• Explain Well Be processes and the care journey.
• Review patient-care interventions and assess patient needs for transitions of care, end-of-life discussions, palliative-care interventions, and medication adherence.

• Support the APP in ongoing panel management and quality-of-care efforts; utilize HEDIS tracking tools to meet and improve HEDIS / STARS performance and close gaps, including medication adherence.
• Contribute complete, accurate, and timely data to patients’ records and ensure all required clinical and non-clinical documentation is in the EMR; complete and submit all documentation daily.
• Collaborate with the interdisciplinary team and participate in regularly scheduled team and Interdisciplinary Team (IDT) meetings, providing additional information on patient and family interactions.
• Build…