All the benefits and perks you need for you and your family:

• Benefits from Day One

• Paid Days Off from Day One

• Student Loan Repayment Program

• Career Development

• Whole Person Wellbeing Resources

Our promise to you:

Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time Days .

Shift: Monday - Friday 8:00am - 4:30pm but could vary based on workload .

Location: .56 Marie Langdon Drive, Manchester, KY

The role you'll contribute: Works collaboratively with specific patient populations, promotes the achievement of optimal clinical and resource utilization allocation, coordinates across the health care continuum for all patients within the physician office setting. Is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum. Works to develop organizational approaches to problem solving. Analyzes current systems and variances to identify opportunities for improvement. Works to promote quality of care through collaboration with all service team members, patients and families. Responsible for coordinating a wide range of self-management support and disease registry activities for the office's patient population. Success will be measured by the results of the process and outcome performance measure of the population of patients in the office. Travel between practices and hospital is required.

The value you'll bring to the team:

• Oversees the management of specific patient populations across the continuum focusing on complex /high risk/ high cost/ and/or multi diagnosis patients. Oversees the disease registry database including: Assuring database is kept up to date; Identifying patients overdue for visits, labs or referrals and arranging for follow-up services as appropriate; Identifying patients not meeting clinical goals, such as blood pressure control or glucose control, and arranging for follow-up services by protocol or as appropriate; Creating patient, physician and office level quality performance reports.

• Conducts and or facilitates pre-visit chart review of patients including: Identification of all needed preventive health maintenance, immunizations and chronic disease interventions; When standing orders allow it the interventions may be ordered or completed before the patient sees the physician; Completes pre-visit forms or initiates office visit forms and communicates the review to the provider.

• Works with patients and families on Self-Management Support including: Setting short and long-term goals for self-management of chronic disease; Addressing medication adherence in patients not meeting outcome goals; Works with patient to create a plan for Health Behavior Change utilizing the 5A's approach (Assess, Advise, Agree, Assist, and Arrange); Assessing and working on the patient's readiness to change, the importance of change and confidence in ability to change; Helping the patient to identify and overcome barriers; Makes a context specific clinically appropriate plan for follow-up between visits; Provides or arranges needed patient education regarding specific health care skills and general disease concepts; Assist with shared medical appointments; Communicating face-to-face in the office setting, or by telephone, or by e-mail; Works independently to assess and evaluate understanding of disease process, treatment plan and / or lifestyle changes.

Qualifications
The expertise and experiences you'll need to succeed:

• Minimum 3 years related experience with an understanding of systems and processes in outpatient medical group practices required

• Current valid license as a Registered Nurse

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