Practice Outreach Coordinator, Licensed Practical Nurse

• Proactive outreach to adult and pediatric primary care patients after transition of care from a healthcare facility including inpatient, emergency department, and skilled nursing facilities.
• Proactive outreach to adult and pediatric primary care patients to support lab/image/referral tracking, gaps in care and other quality measure improvement efforts.
• Effective and compassionate communication with patients and their significant others to plan, implement and follow up on gaps in care.
• Frequent telephonic interactions with patients and their significant other to close gaps in care.
• Coordination with other members of the care team, Providers on the care team and consultants to close gaps in care and update EMR.
• Acts as a liaison between patients, primary care practices and population health and Quality teams in the provision of care.
• Facilitates partnerships with community partners and resources to assist patients in closing gaps in care
• Uses evidence-based coaching techniques to help patients design realistic health goals, implement positive lifestyle changes and achieve desired plan in support of a healthier lifestyle and disease state.
• Works as part of the interdisciplinary team to meet the goals of the Practice, the provider and the patient.
• Will support the population health and transformation initiatives as assigned.
• Provides quality customer service- follows HIPAA rules/regulations.
• As a member of the patient care team, documents in the EMR, the patient interactions and care planning activities as directed by the Provider and care team.
• Identifies and appropriately escalates patient related issues to Provider when required.
• Utilizes data to better understand tailor interventions to the patient populations.
• Attends/presents status updates at meetings.
• Supports the Transformation efforts as needed.
• Regional travel required, use of personal vehicle with mileage reimbursement (consistent with company policy) - drivers license required.
• Other duties and/or projects as assigned.
• Adheres to HMH Organizational competencies and standards of behavior.

• Licensed Practical Nurse (LPN).
• Basic proficiency in standard computer programs e.g., MS Word, Excel, Google Docs, Sheets, etc.
• Ability to work on multiple projects concurrently in a fast paced, timeline driven environment.
• Strong planning and organizational skills with the ability to work independently, multi-task, and prioritize responsibilities.
• Excellent written, verbal and telephone communication skills. Must be able to facilitate webinar meetings.
• Proficiency in Electronic Medical Record required within 60 days of hire.

• Bachelor's Degree is preferred with focus on Health Care administration, principles of management, Population Health, Health Care Education, Community Health, Health Information Management, or Information Technology.

• Licensed Practical Nurse.
• Valid Driver's License from a USA state.

Hackensack Meridian Health