Description

RN+

The following duties may be required, but not all duties will be performed on every work day:

Annual Wellness Visits: performing the virtual portions, including the HRA (health risk assessment).
CCM (chronic care management) or APCM (advanced primary care management) roles/responsibilities.
RPM (remote patient monitoring) oversight as stated below.

Chart Preparation

Perform on all patients with an appointment within 1 month of the current date.
If there are no patients fitting criterion #1, then go back at least 3-6 months, and look at the first 1-3 problems in the assessment/plan section (focusing on patients who have providers no longer with AFM first).
Schedule an in-office follow-up visit for that reason(s) within 1 month of this review, if the patient is not already scheduled for an in-office visit.
Schedule the patient for the appropriate patient visit type.

Nurse Line

Ability to field incoming patient calls (that have previously been filtered by Front Office Staff as appropriate) that are within the RN’s scope of practice.
Ability to refer patients appropriately as an outcome of these calls. For example, scheduling a patient with known hypertension for a follow-up telehealth visit after discovering they have a blood pressure reading of 150/100 with no other presenting signs/symptoms.
Ability to triage stated incoming patient calls into red-yellow-green priority, and determine appropriate next steps as such.

RPM Oversight

Regarding this care program, reviewing the appropriate patient dashboards daily, and triaging patients according to the red-yellow-green methodology. For example, a patient with a blood pressure of 150/100 can be scheduled for an In-Home Program paramedic visit, with immediate care making sure that the patient is not having red-level signs/symptoms.

Care Program Patient Outreach

Regarding AFM’s care programs, having a thorough understanding of the specific program. And, if the patient is eligible for the program, being able to explain the program to them clinically, and obtaining consent, if applicable.

Once the patient is enrolled in the focused-upon program, then performing chart prep to ensure that there are no other gaps that need to be filled in the patient’s care.

Provider schedule double-check: ensuring patients are referred to appropriate care programs, as well as having appropriate provider follow-up.

Inbox Clinician: oversight and completion of inbox messages from patients (and/or other appropriate parties).

Requirements

The appropriate candidate will be aligned with Annandale Family and Internal Medicine's cultural pillars including innovation and professionalism interwoven with our DNA of providing best-in class healthcare for our patients. Also, the ability to display and possess alignment with AFM's mission and vision. Our mission is to serve as trusted, innovative healthcare partners in the community, with our focus centered on individualized care extending beyond the exam room, and that is founded on prevention, wellness, and the whole person. And, our vision is as follows. Imagine an avocado. That is a manifestation of our clinical vision. The flesh portion of the avocado can be imagined as all the items you as a provider do in your daily work life that can be automated, made more efficient, or plainly taken off your plate. We leverage our solutions: efficient, efficacious, and tech-enabled to solve those problems for you. Now, imagine that core of the avocado. That is the centerpiece of the vision, which is the provider’s protected relationship with their patient, the essence of it being evidence-based medicine, practiced with care and compassion. And, the primary benefactor of all of this? It’s the patient, of course!