LPN Care Coordinator

Summary of Position

The LPN Care Coordinator functions in collaboration and ongoing partnership with chronically ill or high risk patients including Mental Health patients with care management needs and their family/caregiver(s) Primary Care Provider and other staff Specialty providers as well as other community resources in a team approach to:

Promote timely access to appropriate care

Increase utilization of preventive care

Create and promote adherence to a care plan developed in coordination with the patient staff primary care provider and family/caregiver(s) through Care ManagementCreate and update with patients a Personalized Prevention Plan during RN-led Annual Wellness Visits

Reduce emergency room utilization and hospital readmissions with patients identified as high resource use in these areas

Enhances cost effectiveness by addressing care gaps and avoiding service duplication

Increase continuity of care by managing relationships with tertiary care providers transitions-in-care and referrals

Increase patients ability for self-management and shared decision-making

Connect patients to relevant community resources with the goal of enhancing patient health and well-being increasing patient satisfaction and reducing health care costs

Increase comprehension through culturally and linguistically appropriate education

Principal Duties and Responsibilities

Work with patients to plan and monitor care:

a) Assess patients unmet health and social needs

b) Develop a care plan with patient family/caregiver(s) and providers

c) Monitor adherence to care plans evaluate effectiveness monitor patient progress in a timely manner and facilitate needed changes and follow up plan(s)

d) Create ongoing process for patients and family/caregiver(s) to determine and request care coordination support they need or desire

e) Evaluate outcomes of care

Lead Annual Wellness Visits as auxiliary staff creating and updating the patients Personalized Prevention Plan and other AWV documentation in the EHR

Identify gaps in care and implement methods to close gaps including those attached to quality/value-based payments and bonuses

Assist in outreach campaigns related to patient engagement quality initiatives transitions of care referrals etc.

Identify high utilizers on transitions of care reporting and perform outreach and patient education as well as evaluate appropriateness of care plan for patients

Educate patient and family/caregiver(s) about relevant community resources

Cultivate and support primary care and specialty provider co-management with timely communication inquiry follow-up and integration of information into the care plan regarding transitions of care and referralsIdentify high risk patients for Care Management utilizing available reports and recommendations by staff/providers

Appropriately and routinely document activities in the patients EHR and care plan

Attend Care Coordinator and other training courses webinars etc. to remain current on regulations practices etc.

Provide feedback to and participate in QA PDSAs and other quality initiatives/projects

Review and track patient outcomes through data systems reporting and dashboards

Perform other duties as assigned

Required Skills or Abilities

1. Ability to manage and prioritize multiple tasks

2. Working knowledge of EHR Next Gen preferred

3. Proficient in Excel Word and PowerPoint and ability to learn other computer programs.

4. Good organizational and self-management skills

5. Excellent verbal and written communications skills

6. Ability to communicate with a diverse range of people from physicians to the patient population

7. Demonstrates knowledge of and adherence to patients rights confidentiality and HIPAA guidelines and regulations

8. Knowledge of local community health and social welfare resources preferred

9. Ability to relate well to people from diverse ethnic and cultural backgrounds

10. Demonstrates working knowledge of PCMH processes and guidelines preferred

11. Ability to travel to different site locations as necessary

Required Knowledge Experience or Licensure/Registration

1. Licensed Practical Nurse with current unrestricted license in the state of Ohio

2. Previous experience in Community Health Center Care coordination and/or case management experience preferred.

3. Current CPR certification.

4. Knowledge of NextGen EHR preferred

5. Knowledge of ICD-10 and CPT coding preferred

Physical Requirements:

Must be able to see sit stand bend stoop hear and lift up to 20 pounds. Must demonstrate

manual dexterity in order to follow necessary clinical procedures.