Pediatric Nurse Practitioner
1 month ago
Job Overview:
This position provides direct and indirect patient care in a primary care office and works with care delivery providers to identify gaps in care, contact patients to schedule required care, and provide referral follow-up.
The Medical Home LPN provides pre-visit planning for the practice's patient panel, coordinates messages through electronic portals, and assists in managing transitions of care.
The Medical Home LPN will act as a clinical liaison to the physician care plan and actively communicate with patients.
Key Responsibilities:
- Coordinates the primary care rooming process, relevant medical procedures, adult and pediatric patient care, including immunizations, venipuncture, point-of-care testing, and performs retinal scan images.
- Follows scheduling decision trees, protocols, and policies for clinical procedures and appropriate use of medical equipment.
- Provides accurate and complete documentation of all facets of care, including clinical calls, patient rooming questions, completion of procedures, order entry, prescriptions, and patient pharmacy, and workflows.
- Addresses messages in a timely manner and escalates issues as appropriate.
- Utilizes and monitors MyChart messaging to support patient communication.
- Participates as a part of the patient-centered medical home team during all patient visits by reviewing the patient chart for clinical gaps in care.
- Assists with outreach campaigns and tactics to close gaps in care.
- Supports and completes pre-visit planning and participates in daily huddles with the physician and care team.
- Embraces the philosophy of wellness and prevention by reminding patients of all screenings and immunizations due by the end of the year.
- Informs the physician of any potential barriers identified by the patient.
- Understands population health and value-based contracts.
- Utilizes key quality and utilization metrics of value-based programs for both wellness and chronic disease management.
- Demonstrates abilities in the Primary Care quality program, including all protocols of well and chronic disease states.
- Identifies patients 'at risk' for change in condition and increased utilization.
- Attends required population health training and education, such as Lunch and Learns and other opportunities.
- Participates in the longitudinal care continuum of patients through completing post-ED/post-inpatient discharge outreach on identified risk patient groups.
- Updates the care team through thorough documentation and works collaboratively with Complex Care RN, Social Worker, CHW, and Population Health Pharmacist.
- Provides basic community resources to patients with social determinants in health.
- Supports and provides education and patient coaching of both wellness and chronic disease management (e.g., Diabetes Education, Colon Cancer Screening).
- Supports facilitating follow-up for post-hospital care, chronic disease management, or specialty referral.
Working Conditions:
Climbing - Occasionally
Concentrating - Consistently
Hearing:
Conversation - Frequently
Interpersonal Communication - Consistently
Kneeling - Occasionally
Lifting
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