Licensed Practical Nurse/Medical Home Coordinator

Job Overview

This position provides both direct and indirect patient care in a primary care office and works with care delivery providers to identify gaps in care, contacts patients to schedule required care, and provides referral follow up.

Job Responsibilities

• Coordinates primary care rooming, clinical procedures, and both adult and pediatric patient care, including immunizations, venipuncture, point-of-care testing, and retinal imaging.
• Follows scheduling decision trees, protocols, and policies while ensuring proper use of clinical equipment.
• Documents all aspects of care accurately, including clinical calls, rooming questions, procedures, orders, prescriptions, pharmacy coordination, and workflow tasks; manages MyChart and patient messages in a timely manner.
• Participates in patient-centered medical home activities by reviewing charts for gaps in care, supporting outreach, completing pre-visit planning, attending daily huddles, and promoting wellness and prevention.
• Applies knowledge of population health and value-based care, using quality metrics for wellness and chronic disease management, identifying at-risk patients, and completing required training.
• Supports longitudinal patient care through post-ED and post-inpatient outreach, thorough documentation, and collaboration with RNs, Social Workers, CHWs, and pharmacists; provides basic community resource guidance.
• Educates and coaches patients on wellness and chronic disease management, helping facilitate follow-up appointments, referrals, and ongoing care coordination.

Working Conditions

• Climbing - Occasionally
• Concentrating - Consistently
• Hearing: Conversation - Frequently
• Interpersonal Communication - Consistently
• Kneeling - Occasionally
• Lifting
• Lifting 50+ Lbs - Occasionally
• Lifting 11-50 Lbs - Rarely
• Pulling - Occasionally
• Pushing - Occasionally
• Reaching - Consistently
• Reading - Consistently
• Sitting - Consistently
• Standing - Frequently
• Stooping - Occasionally
• Using Hands - Consistently
• Color Vision - Consistently
• Walking - Consistently

TriHealth SERVE Standards and ALWAYS Behaviors

• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
• Excel: ALWAYS… Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service
• Respect: ALWAYS… Respect cultural and spiritual differences and honor individual preferences. Respect everyone’s opinion and contribution, regardless of title/role. Speak positively about my team members and other departments in front of patients and guests. Value: ALWAYS… Value the time of others by striving to be on time, prepared and actively participating. Pick up trash, ensuring the physical environment is clean and safe. Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
• Engage: ALWAYS… Acknowledge wins and frequently thank team members and others for contributions. Show courtesy and compassion with customers, team members and the community