Cuyuna Regional Medical Center * Clinic Care Management Baxter, MN Nursing Part Time Over, 8-hour Day Shift FTE: .8 FTE (64 hours per pay period) Weekend Requirements: No weekends Posted 08/13/2024 Req # 13376 POSITION SUMMARY The Population Health & Wellness Nurse is responsible for taking a transformative approach to care that brings together the patient, healthcare providers, and community resources in the planning, implementation, and evaluation of comprehensive healthcare. They help patients define and reach their health care goals resulting in improved health and the prevention of disease exacerbation. The Population Health & Wellness Nurse actively participates in program development, data collection, and process improvement of the Chronic Care Management Program and Medicare Wellness Program. They are responsible for the coordination all aspects of the patient's care, taking a holistic approach and collaborating with the entire health care team for best results. This role is responsible for assessing and managing needs and symptoms, providing patient information, providing support to the patients and their families and ensuring continuity of care for identified patients. They will meet with patients and families in the clinic and hospital. POSITION QUALIFICATIONS Education and Experience: Bachelor of science/art in nursing field preferred. Three years clinical experience in the acute care and/or clinical setting preferred. Previous case management experience preferred. Experience with inpatient and outpatient providers. License/Certificates: RN license to practice in the State of Minnesota. American Heart Association BLS certification required within 30 days of hire. Special Skills and Aptitudes: Knowledge of nursing principles, practices and techniques gained through a variety of nursing experience. Exemplifies self-direction with good organizational, analytical and interpersonal skills. Working knowledge of Electronic Health Records (EHR ) systems. Demonstrate effective communication and interpersonal skills. Exemplify self-direction with good organizational, analytical and interpersonal skills. Knowledge and compliance of state and federal accrediting agencies. Must possess strong interpersonal, verbal and non-verbal communication and problem-solving skills. Ability to handle confidential information discreetly and appropriately. Ability to develop and implement plans for program/department operations. Ability to adapt resources to meet the needs of the situation. Understanding of the health care system and continuum, including sites of care, delivery models, and the roles of various providers. Proficient computer and telephone skills. Possible after-hours availability to assist relevant patients. ESSENTIAL RESPONSIBILITIES Program Development Demonstrate a commitment to the ongoing development of work flows that support chronic care management, annual wellness visits, and ACO requirements. Participate in the development and maintenance of procedures and workflows to capture best practice standards and promote efficiency, including program criteria, documentation, handoffs and billing. Schedule and oversee interdisciplinary team meetings. Direct Patient Care Prepare and administer vaccines according to standard procedure and as ordered by the physician or standing order. Provide patient education and instructions. Complete Annual Wellness Visit (AWV) either as dual model with Physician or nurse only visit. Follow standard work document. Complete vitals, perform Health Risk Assessment and related flowsheets, perform medication reconciliation and complete essential notes in the patient's medical record according to clinic policy. This can be in conjunction with a Physician Appointment or a standalone nurse-only visit. Indirect Patient Care Prep patient chart for Physician. Order annual labs/radiology/consults per Protocol. Accurately capture charges and review ACO platform for Quality Alerts and HCC coding opportunit es. Complete Annual Wellness Visit (AWV) either as dual model with Physician or nurse only visit. Follow standard work document. Assist physician and reception/scheduling staff in maintaining an accurate daily schedule providing efficient patient flow. Assist with scheduling lab tests, Radiology tests, consults or other appointments as ordered per protocol, seeing that all necessary orders are completed. Call, fax, or electronically send patient information or health updates as ordered by physician or standing order and document according to policy. Facilitate communication between patient and physician. Manage voicemail by recording appropriate greetings, checking voicemail, tasking messages to physician for follow up and providing timely follow up to patient. Attend nursing department meetings. Chronic Disease Management Utilize ACO patient registries to identify necessary follow up per guidelines for specific disease/conditions. Assist with audits. Work collaboratively with physicians to manage patient panel and provide feedback. Keep abreast of current guidelines related to chronic disease management and ACO Goals/ Requirement. Assist in ACO education and updates for providers and nursing staff (HCC Coding, AWVs, FCM). Attend monthly ACO meetings and work on process improvement projects. Patient Assessment Enrolled In Care Coordination (FCM Program) Identify high-risk patients based on protocol guidelines. Meet with chronic care management patients to assess needs, develop a plan of care, and coordinate appointments and services. Involve patients in decisions regarding their individual preferences and review medical options in an easy-to-understand vocabulary. Serve as a liaison between physicians and departments to ensure timely quality care is delivered and guide care delivery by all care providers. Act as a clinical resource for patients/families, interdisciplinary teams, and direct care providers. Develop and maintain patient care plans Quality Improvement Promote a culture of continuous improvement through quality monitoring, regulatory compliance, and performance improvement activities. Develop and participate in the measurement and evaluation of care processes to identify variations and opportunities for improvement. Lead program specific process improvement projects. Patient Assessments and Care Coordination Identify high-risk patients based on protocol guidelines. Meet with chronic care management patients to assess needs, develop a plan of care, and coordinate appointments and services. Involve patients in decisions regarding their individual preferences and review medical options in an easy to understand vocabulary. Serve as a liaison between physicians and departments to ensure timely quality care is delivered and guide care delivery by all care providers. Act as a clinical resource for patients/families, interdisciplinary teams, and direct care providers. Develop and maintain patient care plans. Community Outreach Build and maintain relationships with community programs and resources. Refer to appropriate internal and/or community resources as needed. At minimum, partake in quarterly community outings. Promote AWVs, Health Care Maintenance, Wellness, CRMC fundraisers, Chronic Disease maintenance/education (ex: Blood Pressure booths, Health Care Directive education) Education Prepare and provide education for staff on subjects related to the chronic care management program and wellness program. Plan for and provide patient, family, caregiver education by identifying needs and communicating information clearly. Document education process and response. Participate in in-service programs,... For full info follow application link. Cuyuna Regional Medical Center is an Equal Opportunity Employer.