Annual Wellness NursePopulation Health Facilitator

Caring For the Community You Love

Choose a career to make a difference in peoples lives every day choose Fisher-Titus!

Perks of working at Fisher-Titus:

• Hours of Work- Full time
• Comprehensive Benefits Package- Medical & Dental coverage 401K match paid time off tuition assistance and more!
• Shift Weekend & PRN differential

About Fisher-Titus:

Fisher-Titus proudly serves the greater Huron County areas 70000-plus residents by providing a full continuum of health and wellness care from heart and cancer care to outpatient services such as lab imaging and physical rehabilitation.

Vision: Be the first choice for healthcare and employment within our community

Mission: Deliver compassionate and convenient care to the highest level of excellence that promoteslifelong health and wellness for our community

General Summary:

The Annual Wellness Nurse/Pop Health Facilitator works collaboratively with physicians and the care team to ensure patient adherence to the medical plan of care and/or evidence-based medicine guidelines including all appropriate preventive and disease-specific screenings interventions and treatment goals; including self-management goals and contact schedules.

Essential Functions:

• Communicate with populations of patients via telephone electronically correspondence or otherwise to support patient adherence to plan of care and/or evidence-based medicine guidelines.
• Maintain an active case load of at risk patients using identification and stratification tools direct referrals from the patients healthcare team (physician Care Coordinator hospital case manager etc.) and other clinical knowledge.
• Work with at risk 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. Creating a plan for health behavior change.
• Performing individual needs assessment care plan design documentation and implementation and evaluation of outcomes.
• Communicating with patients face-to-face by telephone or by email.
• Communicating a plan for healthcare needs between physician/office visits.
• Providing needed patient education regarding specific health care skills and general disease concepts by supplying informational materials directing the patient to health plan resources approved websites or community resources.
• Working toward reduction of preventable hospital admissions re-admissions excessive therapies DME etc.
• Floats and/or works at other locations to support operational needs.

This position requires expertise in the nursing process using critical thinking skills to plan and coordinate care. The AWN is responsible and accountable for direct and indirect patient care for designated patient populations.

Although primarily performed by a LPN the role of an Annual Wellness Nurse can be accomplished as an RN with understanding that salary will be established at an LPN level.