Population Health Nurse(LPN/RN)

Job Summary: The Population Health LPN will promote health and prevent disease in communities. Must be proactive in helping patients identify symptoms before they worsen, focusing on risk before they occur.

Job Summary: The Population Health LPN will promote health and prevent disease in communities. Must be proactive in helping patients identify symptoms before they worsen, focusing on risk before they occur.

Job Duties:

1. Assess health needs, identify health problems and community trends.
2. Develop intervention plans, create plans to help patients improve health and safety
3. Monitor patient vitals signs via internet connected device and information platform. Will personalize each patient individually according to provider orders.
4. Educate/Coach patients, provide information regarding disease specific issues and help identify ways for the population to live a healthier life.
5. Evaluate plans, use data to improve patient life.
6. Help providers and office staff to improve upon communication, education to patients. Will assist the office staff to schedule patients for appointments as needed.
7. The Population Health LPN will coordinate other services for the patient within Population Health, including but not limited to, CHF education, diabetic education, Medicare annual wellness services, transitional care, and community services as needed.
8. Population Health LPN will work with providers patients offering education to patients on disease specific information, will educate patients on how to use remote patient monitoring equipment, and symptom management.
9. Population Health LPN will take accurate information regarding symptoms, provide details regarding patient condition, be knowledgeable of medications. The Population Health LPN will communicate effectively with providers and follow up with pertinent information to provider and patient.
10. The Population Health LPN will have frequent outreach to patients to manage chronic conditions, develop personalized care plans for each patient. The Population Health LPN is expected to become a trusted resource for the patient to call and report changes in condition.
11. The Population Health LPN will document using technology platforms and EHR.
12. The Population Health LPN will connect patients with resources and prepare them for medical appointments. The Population Health LPN will support and encourage patients to maintain compliance with monitoring device.
13. The Population Health LPN will run monthly reports, assist with month end billing. Responsible for following CMS guidelines to ensure billing is done correctly and efficiently. Must ensure all clinical documentation meets CMS requirements.
14. The Population Health LPN will also communicate with home care providers to help with transitions of care for the patient.
15. The Population Health LPN will help to maintain the patient record, ensuring all information is up to date.

• Active LPN license in Indiana
• Preferred to have Home Health Experience
• Proficient in Microsoft Office/Excel
• Organized individual that can communicate effectively.
• Job hours can be flexible.
• Applicant must be able to work independently and as a part of a team.
• Must have strong ethics and values
• Be a critical thinker, and strong ability to solve problems.