LVN Healthcare Coordinator NW 410

Primary Responsibilities

• Works with the providers and clinic staff to identify patients at high risk through transitions of care. This is to support the market initiative of reducing utilizations, including ER visits, hospital admissions, and hospital readmissions.
• Supports longitudinal care of the patient with chronic care conditions by:
• performing assessment of health conditions
• initiating medication reconciliation for PCP to complete
• conducting Motivational Interviewing and Self-Management Goal setting
• providing patient education
• Supports transition of the patient with chronic care conditions from inpatient to outpatient setting, by:
• performing assessment of transitional needs
• initiating medication reconciliation for PCP to complete
• establishing and reviewing contingency plan and 24/7 patient support availability
• providing patient education in a self-management format
• completing 3 in 30 on all high risk members experiencing a discharge
• ensuring a 7 calendar day follow up with PCP post discharge
• assisting with post discharge needs such as prescriptions, transportation, Durable Medical Equipment (DME), appointments by creating and following up on social work referrals
• refers to case management for complex case needs, longitudinal needs, and/or disease management
• Cook with providers to establish or update plan of care
• Performs accurate and timely documentation in the electronic medical record
• Participates in daily huddles and Patient Care Coordination (PCC) meetings
• Prepares accurate and timely reports, as required, for weekly meetings
• Maintains continued competence in nursing practice and knowledge of current evidence based practices
• May perform clinical tasks within their scope of practice
• Performs all other related duties as assigned

Required Qualifications

• Licensed Practical/Vocational Nurse with an active and unrestricted license to practice in the state of employment
• Current BLS certification
• 2+ years of experience in a physician's office, clinical or hospital setting
• Proven knowledge of chronic diseases, especially COPD/asthma, diabetes, CHF and IHD
• Proven excellent verbal and written skills
• Proven solid interpersonal skills
• Ability to interact productively with individuals and with multidisciplinary teams
• Proficient computer skills to work efficiently with electronic medical records
• Proven excellent organizational and prioritization skills

Preferred Qualifications

• IV Certification
• Experience related to patient education and/or motivational interviewing skills and self-management goal setting
• Experience with outbound patient telecommunications
• Fluent written and verbal skills in English and Spanish

Pay and Benefits

• Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc.
• In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
• No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives.
• The hourly pay for this role will range from $20.00 to $36.00 per hour based on full-time employment.
• We comply with all minimum wage laws as applicable.