Meadville Medical Center Health Systems Population Health Nurse in United States

PURPOSE: The Wellness RN will improve patient health outcomes by focusing on preventative care, identifying and enrolling patients in appropriate programs, working with the patient's care team and accountable care organization experts to provide direct telephone-based care management services to address challenges that affect the patient's health, scheduling and performing Medicare Annual Wellness Visits (AWV) for enrolled patients, and keeping enrolled patients continuously engaged in their care. The Wellness RN will support other population health initiatives as needed. JOB DUTIES: Review patient data within the ACO population health tool and EHR to identify and schedule appropriate patients for AWVs. Initiate outreach to identified patients to educate about AWVs and scheduled interested patients. Track scheduled patients to determine outcome of scheduled appointments and determine next steps in plan of care. Ensure scheduled patients receive (via mail or other means) packet of forms to be completed prior to AWVs and brought in to scheduled AWVs for review by medical team. Perform screening questionnaires and assessments of AWVs as requested, such as health risk assessment, medical and family history, functional ability and level of safety, updating EHR with information obtained. Conduct pre-visit planning for AWV, including working with the provider to determine screenings and preventative services patient may need prior to scheduled AWVs. Travel independently between 4 sites to perform scheduled AWVs. Perform AWVs, including rooming the scheduled patient; obtaining patient history by reviewing the Health Record Assessment (HRA) completed by the patient; identifying current providers and medical suppliers utilized by the patient; taking the patient's medical and family history; performing identified screenings and assessments; and reviewing personalized health plan at end of visit. Ensure effective tracking of test results, medication management, and adherence to follow-up appointments. Provide case management support as requested for other population health initiatives. Provide offsite support to the nursing team to address patient or staff needs related to patient care. MINIMUM QUALIFICATIONS: Professional knowledge of nursing theory and practice at a level normally acquired through completion of an accredited School of Nursing. Current BLS Healthcare Provider card required. Minimum of 1 years' experience with direct hands on care of patients required. Current State RN License in Pennsylvania.