Patient Care Advocate; LPN

Overview

The Well Be care model is a Physician-Led Advanced Practice clinician-driven geriatric care team focused on the care of frail, poly-chronic elderly Medicare Advantage patients. This population is typically underserved and challenged with access to care. To address these problems, the model brings care to the patient, rather than requiring the patient to come to care. Care is provided throughout the entire continuum—from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end-of-life care.

Well Be’s physician- and clinician-led geriatric teams partner with the patient’s primary care physician to provide concierge-level geriatric medical care and social support in the home as well as coordinating across the care continuum.

Our Patient Care Advocate (PCA) is an energetic, curious explorer who provides compassionate care to the frailest elderly living in their homes. The PCA develops rapport, delivers exceptional in-home services, coordinates care with the medical team, schedules appointments with our team and specialists, coordinates diagnostic tests, manages HEDIS gap closure, serves as a community resource, engages patients who are not currently engaged, and ensures complete and accurate data in patients’ records and other tracking tasks.

The successful candidate loves working with seniors and collaborating in an interdisciplinary team and thrives in a positive, upbeat work environment.

• Practice the Well Be mission to help patients lead healthier, meaningful lives by delivering complete care.
• Act as a community resource for the patient.
• Provide support during comprehensive initial visits when needed.
• Manage patient medical records as appropriate.
• Complete drop-in visits for unengaged patients or open HEDIS gaps.
• Answer patient non-clinical questions and explain the process.
• Ensure all appropriate patient documentation for non-clinical summaries is in the EMR.
• Provide positive customer service and treat all patients and staff with respect.
• Collaborate with the interdisciplinary team and participate in regularly scheduled team meetings as directed by the supervisor.
• Complete non-invasive patient screenings and testing.
• Clearly explain POCT to geriatric patients.
• Escalate patient clinical concerns to APP, CD, CMD.
• Support APP in ongoing panel management and quality of care efforts (e.g., HEDIS).
• Utilize HEDIS tracking tools, meet and improve HEDIS STARS performance.
• Perform other tasks needed to accomplish the team’s objectives and goals.

• High school graduate or GED.

• LPN Certification.

• 2+ years of patient-facing experience in a healthcare practice or hospital.
• Current BLS card for healthcare providers or willingness to obtain one.
• EMR documentation experience preferred.
• High level of professionalism.
• Strong customer geriatric focus/service skills.
• Strong computer skills, including Word, Excel, and PowerPoint.
• Strong verbal, written, presentation, and interpersonal communication skills.

$44k to $55k

4 days in field, 1 day in office.

Travel is required locally. The role is field-based, visiting patient homes.

Well Be is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected status.