LPN CARE COORDINATION PROGRAM - FULL TIME

About the Role

The LPN Care Coordinator is an essential member of the Value Based Services team at Watson Clinic. He or she will work with both the care teams and the patients to support the goals of providing efficient, effective, and quality care to our community by managing patients with complex needs, including Transition of Care Management and Chronic disease management, active care planning, and addressing barriers to care.

Responsibilities

• Identify patients for inclusion in the program utilizing available metrics and reduce barriers to care using health plan services, community resources, and organizational support.
• Perform comprehensive patient assessments upon entry to service and periodically, including evaluating patient and family support systems and needs.
• Contact patients telephonically for care coordination and medication reconciliation post-discharge (hospital and skilled nursing).
• Assist patients in gaining access to PCP and specialist appointments as needed.
• Follow established protocols to educate patients on disease management and promote patient self-management.
• Follow up on DME needs (met or unmet) and home health agency issues.
• Perform case reviews for the ‘fragile few’ to present to treating physicians.
• Develop and implement individualized, goal-driven patient care plans focusing on disease management and patient empowerment.
• Assist patients and families with navigating their health care plans and accessing community resources.
• Monitor care plans and patient progress toward goal achievement; revise plans as necessary and provide education and support.
• Maintain contact with patients and families through transitions of care while coordinating with other care team members.
• Participate as an active member of the patient’s care team, collaborating with patients, families, providers, clinic staff, and other care partners.
• Document all encounters and patient-related discussions (telephonic or in-person) in the EHR.
• Conduct home, hospital, and clinic visits as appropriate, following established guidelines, policies, and procedures.
• Process billing transactions for Transition of Care Management.
• Utilize Microsoft Product Suite, including Excel for data insertion from EHR and Word for creating narrative reports on project status.

Requirements

• Graduate of an accredited Licensed Practical Nurse program.
• Florida licensure required.
• Two years’ experience working in both inpatient and ambulatory care settings (e.g., physician office, hospital, or Hospice).
• Proficiency with Excel.
• Excellent listening and interpersonal skills.
• Ability to maintain confidences.
• Must be flexible, resourceful, and able to problem-solve.
• Must be able to handle multiple tasks simultaneously and set priorities.

Preferred Qualifications

• Bachelor’s degree.
• Case Management Certification.