Avance Care
Population Health Nurse - Alo Solutions (Information Technology)
Provides superior customer service to patients by exhibiting respect, empathy, active listening, and clear communication skills through telephonic outreach to patients.
Performs nursing assessments to identify risk factors, level of comfort with self-care and knowledge deficits and creates a patient-centered plan of care, as applicable.
Offers health coaching through relevant communication methods, such as motivational interviewing and teaching, followed by targeted interventions, as appropriate.
Provides disease management by identifying barriers to care through a holistic approach, making appropriate referrals, connecting patients to resources, coordinating health services between different providers, and acting as a patient advocate.
Supports management of many aspects of the patient's care including follow up to ensure compliance with treatment plan.
Participates in closing gaps in care by educating patients and utilizing standing orders.
Assists patients with more seamless transitions of care from inpatient and emergency department settings back to home or community.
Facilitates and/or completes medication reconciliation and educates patients in regards to their medication regimen.
Collaborates with other members of the care team and VBC team.
Draws relevant patient data from multiple sources, such as electronic medical records, claims data, payer portals, ACO reports and others.
Maintains appropriate clinical documentation of all patient-related activities, including, but not limited to, virtual patient encounters, outreach efforts, and communication events.
Participates in quality validation, and/or process improvement activities.
Demonstrates proficient use of computer software, telephone system and general office equipment.
Performs other duties as assigned.
KNOWLEDGE, SKILLS, ABILITIES AND OTHER QUALIFICATIONS:
Registered nurse (RN) license.
At least 3 years of experience in population health, quality, HEDIS, chronic care management, or a similar environment.
Experience working with electronic medical records.
Excellent verbal, written, and presentation skills.
Excellent PC skills and knowledge of programs such as Microsoft Office.
Demonstrated ability to communicate effectively and professionally, with all levels of management.
Must be able to work independently and demonstrate initiative as well as problem-solving skills within a fast-paced, ever-changing, start-up environment.