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Full-time (80 hours biweekly)

Weekdays, daytime hours; 8 am to 4:30 pm

Part of the Value Based Payor Team; WellSpan footprint

Hybrid remote work which includes on-site meetings in York, Chambersburg and Gettysburg

General Summary

Provides safe, therapeutic and efficient care and services to patients. Supports the care team by functioning as a health coach for disease prevention and early screening, testing and treatment. Helps patients manage their chronic diseases. Assists in the care of patients, and instructs patients and their families in appropriate care, as directed by their provider. Functions as a member of the care team to assist in the planning and implementation of patient care based upon sound clinical preparation, knowledge, skills and experience. Provides practice and guidance to the patient/caregiver for effective care transitions, improved self-management skills and enhanced patient-practitioner communication. Care is provided in accordance with the provisions of Practical Nurse Licensure with the Pennsylvania State Board of Nursing.

Remote Work Capable

Essential Functions:

+ Provides support to patients of the practice for clinical outcome management, healthy lifestyle information, via appointment coordination and navigation of the health system.

+ Completes transitions of care calls for moderate risk patients discharged from Hospital/ED and thoroughly documents. Arranges follow-up services and identifies issues and concerns to appropriate staff as needed.

+ Communicates and shares information with providers and care team members on issues and concerns such as transition of care between hospital, skilled nursing facility, rehab and home care. Supports the care team by functioning as a health coach for disease prevention, early screening and testing and treatment and for helping patients manage chronic diseases.

+ Generates/review payer lists of patients in order to proactively manage patients and families with service needs for prevention or chronic conditions.

+ Supports the care team by functioning as a coach for disease prevention, early screening and testing and treatment and for helping patients manage chronic diseases.

+ For patient populations where Wellspan is at financial risk, provides direct care management interventions by completing the Shared Care Plan. Interventions include: assisting patients with goal setting, creating action plans to manage their health, addressing barriers to patient adherence to treatment plan, assisting patients with referrals utilizing wellness and self-management programs.

+ Assists patients with instruction and health literacy through teach back of any new medications, instructions and referrals. Monitors outcomes while following up on interventions identified in the care plan within scope of practice. Provides health care information materials and reviews with patient and or family members as directed by providers.

+ Maintains the patient's records to ensure an accuracy of the patient's medical treatment. Documents in the patient record under the direction and supervision of the care provider.

+ Uses Motivational Interviewing techniques to engage patients in self-management skills.

+ Ensures practice meets the standards to bill for chronic coaching services.

+ Addresses and mitigates patient social determinants of health needs that could negatively impact care plan follow through.

Common Expectations:

+ Demonstrates a commitment to safety and quality by following established policies and procedures, reporting concerns, and participating in efforts to reduce risk and improve care.

+ Provides exceptional service to patients, providers, coworkers, and visitors by fostering teamwork, maintaining professionalism, and supporting a respectful, clean, and efficient work environment.

+ Engages in professional development and contributes to department goals by attending required meetings, using technology effectively, and identifying opportunities for improvement.

Minimum Education:

+ Certificate Program Post High School Vocational/Specialized Training Required

Work Experience:

+ 1 year Healthcare experience required

Licenses:

+ Licensed Practical Nurse Upon Hire Required or

+ Licensed Practical Nurse Multi State License Upon Hire Required or

+ Basic Life Support Upon Hire Required

Courses and Training:

+ Completes all required education programs and competency testing needed to perform at an advanced level. Upon Hire Required

Knowledge, Skills, and Abilities:

+ Proficient communication skills including SBAR technique.

+ Ability to effectively present clinical information to the care team.

+ Proficient in navigating and entering information into an electronic health record.

+ Models team work.

+ Self-motivated and dependable.

+ Able to work independently.

Benefits Offered:

+ Comprehensive health benefits

+ Flexible spending and health savings accounts

+ Retirement savings plan

+ Paid time off (PTO)

+ Short-term disability

+ Education assistance

+ Financial education and support, including DailyPay

+ Wellness and Wellbeing programs

+ Caregiver support via Wellthy

+ Childcare referral service via Wellthy

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org) (https://www.joinwellspan.org/benefits/)

WellSpan Health's vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest.

Quality of Life

Franklin County, named after Benjamin Franklin, was officially formed in 1784. One of its two main towns, the borough of Chambersburg, lies 13 miles north of Maryland and is known for its "green, safe environment." In the southern part of Franklin County, the borough of Waynesboro sits just two miles north of the Mason-Dixon Line and is known for its rich industrial history.

Franklin County is in the heart of Central Pennsylvania, where you'll find mountains, lakes and a picturesque countryside coupled with theater, music, skiing, hunting, fishing and much more. We're in the heart of America's fruit orchards, so peaches, apples and lots of other local produce are available close by. The area features local wineries and breweries, along with a vibrant arts scene at the historic Capitol Theatre and Totem Pole Playhouse. Franklin County merges the best of small-town friendliness with easy access to metropolitan areas. (Patient population: 154,000)

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.