Care Coordinator/LPN

About the role

The Care Coordinator/LPN will be responsible for monitoring and coordinating population-health management activities at one or more health center locations. The primary function of this position will be to work in collaboration and continuous partnership with chronically ill or "high-risk" patients and their family/caregiver to promote timely access to appropriate care, increase utilization of preventative care, reduce emergency room utilization and hospital readmissions, increase comprehension through culturally and linguistically appropriate education, promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver. Using a team-based approach, the care coordinator will act as a resource to patients and health care staff to ensure patients receive all the care and services they require.

Responsibilities

• Identify patients for care coordination via generating patient registries, MCO care gap lists, Medical Home Network (MHN) portal, etc.
• Conduct timely patient outreach/engagement and follow up activities, via telephone, direct mailing, face-to-face and/or electronically, to new and established patients and to schedule coordinate appointments as needed.
• Track, monitor, and schedule follow-up appointments for patients recently discharged from the hospital or ER; collaborate with care team for patient needs.
• Absorb and communicate with care team, with transitions to care, navigating health care services and linkage to community resources and support.
• Regularly collaborate, coordinate, and communicate with care team member(s) to resolve outstanding patient care related items (care gaps; outstanding referrals, follow up paperwork etc.).
• Assist with data collection and reporting for targeted clinical quality measures.
• Absorb and communicate with patients, health care staff, community partners, external agencies, etc.
• Maintain confidentiality of all medical records by adhering to HIPAA guidelines when handling patient information and sensitive documents.
• Implement and maintain department’s process for logging/tracking all patient outreach efforts made (i.e. appointment scheduling).
• Timely and accurate completion of all care coordination tasks and assignments by deadlines.
• Provide back up support and assistance with care team activities (i.e. referral functions) as needed and assigned.
• Maintain professionalism at all times when communicating with patients, staff members, community partners, external agencies, etc.
• Adhere to all policies, procedures, and protocols of the agency and department.
• Participate and adhere to NCQA Patient Centered Medical Home (PCMH) standards and quality improvement (Q.I.) related activities as assigned.
• Attend meetings and trainings as scheduled.
• Meet individuals and department targeted productivity goals, objectives and performance ratings.

Requirements

• LPN Illinois licensure or equivalent from an accredited school/program required.
• Prior experience as an LPN is strongly preferred; experience as an EMT, CNA, M.A. or community health worker is also a plus.
• Prior work experience in a clinic, hospital or health care agency setting preferred.
• Knowledge of medical terminology and systems a plus.
• Must be detail-oriented, organized and have the ability to multi-task and work in a fast-paced environment.
• Knowledge of insurance authorization process for Medicaid/Medicare and private commercial insurance.
• Must possess excellent customer service and writing skills.
• Position requires computer literacy; prior electronic health records (EHR) experience strongly preferred.

Qualifications

• Able to work independently.
• Able to work and communicate well with all age groups.
• Flexible work schedule to meet clinic hours.
• Willing to travel to school-based clinic, meetings and other satellite sites as necessary.
• Able to adapt to change and maintain a professional demeanor.
• Able to handle a fast-paced diverse workplace in a team environment.
• Excellent interpersonal/oral communication skills and organizational and typing skills preferred.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to walk and stand regularly. Required to be able to type proficiently, write legibly and read a computer monitor, as well as printed or handwritten materials. Needs to be able to communicate and respond effectively. Occasionally may need to crouch, kneel, stoop or bend. Must be able to use fingers, hands and arms extensively to draw blood, administer injections and attend to other aspects of patient care. Ability to assist with moving or lifting equipment and patients up to 50 pounds Visual acuity to perform tasks requiring close vision and ability to adjust focus. Ability to travel to the School Clinic.

Working Conditions

Clinical Setting. OSHA – Highly likely to produce blood or body fluid exposure.