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.

Responsibilities

• Identify patients for inclusion in the program utilizing available metrics.
• Identify and reduce barriers to care utilizing health plan services, community resources, and organizational support as appropriate.
• Perform comprehensive patient assessments upon entry to service and periodically, including an assessment of patient and family support systems and needs.
• Contact patients telephonically for care coordination and medication reconciliation post-discharge for hospital and skilled nursing discharges.
• 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 the treating physician.
• Develop and implement individualized, goal-driven patient care plans with a focus on disease management and patient empowerment.
• Assist patients and families with navigation of their healthcare plan.
• Monitor care plans and patient progress toward goal achievement; revise plans as necessary, providing education and support as appropriate.
• Assist patients and families in accessing available community resources.
• 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 as appropriate for Transition of Care Management.
• Utilize Microsoft Product Suite, including data insertion in Excel spreadsheets and creating narrative reports in Word for project status updates.

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.

Skills

• Excellent listening and interpersonal skills.
• Ability to maintain confidences.
• Flexible, resourceful, and able to problem-solve.
• Ability to handle multiple tasks simultaneously and set priorities.

Preferred Qualifications

• Bachelor’s degree.
• Case Management Certification.