May 24, 2023 |

Department: ACO/Wellness

Status/Schedule: Full Time

Shift: Days

Location: Hartford, KY

For more information contact: Bridget Johnson, bjohnson@ochcares.com


  • Education: Licensed by the Kentucky Board of Nursing as a RN or LPN
  • Experience: Preferred 2 years
  • Additonal: BLS or be willing to obtain within 12 months of hire

Job Description:

  • Enroll, monitor, and educate patients in our Chronic Care Management program.
  • Provide continuing care after hospital discharge for Medicare patients through our Transitional Care Management program
  • Perform and schedule annual wellness visits under the guidance and supervision of our medical providers.
  • Set performance goals with ACO Coordinator to strive for Outstanding Care Here each month.
  • Participate in daily huddles with Wellness Team. Identify scheduling opportunities, determine special needs for patients arriving at that office/clinic day, identify patients overdue for AWV and those with missed appointments needing rescheduling. Ensure sharing of positive patient stories or compliments involving care team efforts.
  • Ensure review of patient record to identify gaps in problem list prior to provider visit, post reminders to secure that all comorbidities are discussed and documented during AWV.
  • Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider.
  • Establish counseling services or providing resources to assist with obesity, tobacco cessation, diabetes prevention/management, depression, anxiety and managing cardiovascular disease as directed by the provider.
  • Our ultimate goal is to help patients succeed and reduce hospital admissions for Medicare patients
  • Can pay attention to detail and accuracy of documentation of records.
  • Has the ability to work in a high-volume caseload environment and deal effectively with rapidly changing priorities.
  • Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, providing throughout patient education, and working with disparate populations preferred.
  • Ability to identify and implement appropriate patient communication strategies.
  • The demonstrated ability to work constructively with all disciplines related to caring for patients within the community.

Ohio County Healthcare

Ohio County Healthcare is a non-profit Joint Commission accredited health system which provides a wide range of hospital, primary care and specialty physician services.

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