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.

The Medical Home LPN provides pre-visit planning for the practice's patient panel, coordinates messages through electronic portals, and assists in managing transitions of care.

The Medical Home LPN will act as a clinical liaison to the physician care plan and actively communicates with patients.

The LPN participates in process improvements, is knowledgeable of clinical goals and outcomes including patient satisfaction and engagement.

Job Responsibilities

• Clinically assess and document patient care, including clinical calls, rooming questions, procedures, orders, prescriptions, pharmacy coordination, and workflow tasks.
• Manage MyChart and patient messages in a timely manner.
• Participate 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.
• Apply 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.
• Support longitudinal patient care through post-ED and post-inpatient outreach, thorough documentation, and collaboration with RNs, Social Workers, CHWs, and pharmacists; provide basic community resource guidance.
• Educate and coach 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
• Sitting - Consistently
• Standing - Frequently
• Stooping - Occasionally
• Thinking/Reasoning - Consistently
• 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.