Population Jobs in Kentucky (NOW HIRING)

Weekend Requirements: N/A | Work Hours: 8:00-4:30 | Status: Full Time - 1.0 FTE (80 hours per pay period) | Entity: Owensboro Health Clinically Integrated Network | Department: Population Health
Job Summary:
Oversees care management and coordination activities for patients of a primary care practice.
Job Responsibilities:

• Works with clinical teams as a resource on care management of patients including pre-visit planning workflow to ensure care completion prior to visit and after-visit summary review with patients when appropriate.
• Involves the patients in activities to improve their health (patient engagement) and educates patients about self management tasks they can undertake to gain greater control of their health status.
• Works with physician leadership to develop protocols and point of care reminders using nationally recognized EBC measures and outcomes. Defines quality measures and outcomes reporting processes. Serves as a resource to clinical staff and providers to establish quality goals using reports.
• Works with IT resources to facilitate registry reporting at the site and documentation of EBC in searchable fields.
• Works with IT resources to coordinate efficient consult request communication and consistent documentation of patient self-management measures, mutually agreed upon care plan that is efficiently available to all, and reporting of progress towards goals.
• Manages assigned panel of chronic care patients (high acuity).
• Develops relationship with patients as an integral member of team by providing follow-up contact with patient as indicated to ensure compliance with recommendations--medications, lab/x-ray, specialist visits, PCP visits, dietitians, CDE, etc. Manages many aspects of the patient's care including referral to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services.
• Provides telephone advice per protocol and handles urgent and emergent calls.
• Works with patient and patient's care team to coordinate change readiness, needs assessment and develops an individualized treatment care plan.
• Assists patient in setting SMART goals for self-management, teaching them how to do self-management tasks, and report abnormal findings to their physician team.
• Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward individual health care goals.
• Assesses barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
• Oversees the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
• Collaborates with payer Care Managers for additional services when appropriate.
• Develops a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
• Works with consulting physicians, hospitals, emergency department, and other frequently used healthcare sources to clarify roles, develop effective, efficient, and timely communication between primary care physician (PCP) and these entities.
• Facilitates physician leadership to develop written agreements with consulting physicians, key facilities, and community resources to define the roles and method of communication.
• Coordinates consultations and/or referrals, hospital/emergency department, community resources follow-up and tracking process for the practice; works to have clerical component done by appropriate clerical staff whenever possible.
• Develops workflows and protocols within the individualized treatment care plan that ensures emergency department, hospital, and community resource follow-up.

Skills and Attributes:

• Requires critical thinking skills and decisive judgment.
• Works under minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

Position Requirements:
Work Experience

• No experience required

Education

• Bachelor's degree or higher in Nursing required upon hire

Licensure/Certification/Registration

• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire AND
• BLS - Certified as a Basic Life Support Healthcare Provider required within 45 days of employment in this position

Organizational Responsibilities:

• Supports Owensboro Health's Mission, Vision, Core Commitments, and business interests. Adheres to all organizational policies and procedures. Executes all tasks and behaves in a manner consistent with a culture of compliance, safety and a high reliability organization.

Additional Job Information:

• This job description describes the general nature and level of work required by the position. It is not intended to be an all-inclusive list of qualifications, skills, duties, responsibilities or working conditions of the job. Specific duties and responsibilities consistent with the general nature and level of work described may vary by department and additional related duties may be assigned as needed. Some duties listed may not apply to all employees with this job description.
• The job description is subject to change with or without notice, and Management reserves the right to add, modify or remove any qualification or duty. Nothing in this job description changes the existing at-will employment relationship between the Organization and the employee occupying the position.

Standard ADA Settings:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical Demands: (Office Environment)
Standing: Occasionally
Walking: Occasionally
Sitting: Frequently
Lifting 0-25 lbs.: Rarely
Lifting 25-75 lbs.: Rarely
Lifting over 75 lbs.: Rarely
Carrying 0-25 lbs.: Rarely
Carrying 25-75 lbs.: Rarely
Carrying over 75 lbs.: Rarely
Pushing/Pulling 0-25 lbs.: Frequently
Pushing/Pulling 25-75 lbs.: Rarely
Pushing/Pulling over 75 lbs.: Rarely
Climbing: Rarely
Bending/Stooping: Rarely
Kneeling: Rarely
Crouching/Crawling: Rarely
Reaching: Occasionally
Talking: Frequently
Hearing: Frequently
Repetitive Foot/Leg Movements: Rarely
Repetitive Hand/Arm Movements: Frequently
Keyboard Data Entry: Frequently
Running: Rarely
Vision: Depth Perception: Frequently
Vision: Distinguish Color: Frequently
Vision: Seeing Far: Frequently
Vision: Seeing Near: Frequently
Hazardous Drug Risk Exposure:
Risk Level: Low-Risk
Owensboro Health Core Commitments
INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.
RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.
TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.
INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.
SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.
EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.