Perform Annual Wellness Visit in accordance with Payer and CH guidelines. Assess the healthcare, educational, and psychosocial needs of the patient/family and involves them in establishing a treatment plan based on realistic goals and interventions. Investigate healthcare options and facilitate communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify interventions for treatment. Use motivational interviewing and shared dec... more details
Overview Catholic Health is one of Long Island’s finest health and human services agencies. Our health system has over 16,000 employees, six acute care hospitals, three nursing homes, a home health service, hospice and a network of physician practices across the island. At Catholic Health, our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence based practice to improve outcomes – to every patient, every time. We are committed to caring for Long Island. Be a part of our team of healthcare heroes and discover why Catholic Health was named Long Island's Top Workplace! Job Details Responsibilities: Perform Annual Wellness Visit in accordance with Payer and CH guidelines. Assess the healthcare, educational, and psychosocial needs of the patient/family and involves them in establishing a treatment plan based on realistic goals and interventions. Investigate healthcare options and facilitate communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify interventions for treatment. Use motivational interviewing and shared decision-making modalities as appropriate to enhance patient engagement. Educate patient, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and makes referral to appropriate Care Coordination services as needed. Collaborate with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. Coordinate laboratory and diagnostic tests for disease management and value-based payment programs. Collect and enter data and patient information into the medical record according to department and CH standards. Attend and participate in professional and nursing continuing education programs and professional development opportunities. Review the current literature regarding effective teaching/learning strategies and disease management strategies and incorporate the appropriate techniques into practice. Incorporate excellent written, verbal, and listening communication skills, team-building skills, and critical thinking skills in disease management practice. Qualifications: Education: Bachelor of Science in Nursing (BSN) degree required; Master of Science degree preferred Licensure: New York Registered Nurse (RN) License & Registration required Prior population health experience preferred; AWV familiarity a plus. Minimum of 3 years ambulatory experience required Strong background in ambulatory care prevention, health promotion, condition management, case management and discharge planning. Mastery of theories, principles and methodologies underlying population health management and clinical preventative services. Knowledge of contemporary practice transformation models, e.g., PCMH, APC Proficient in Microsoft Office (Excel, Power Point, and Microsoft Word), Outlook (email), and internet familiarity is required. Knowledge of EMR (EPIC preferred) Salary Range USD $114,000.00 - USD $125,000.00 /Yr. This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, or other forms of compensation that may be applicable to this job and it does not include the value of benefits. At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.
