Job Title: Licensed Practical Nurse (LPN) - Care Coordinator
FLSA Status: Exempt
Minimal Qualifications:
Experience: At least 1 year of experience in working directly with electronic health records (EHR) in an ambulatory setting or prior work experience in a clinic setting doing referral care coordination or similar nursing duties.
Skills:
• Graduate of an accredited Nursing Program • School Valid in the state of Illinois • RN license preferred • Current BLS certification • Valid drivers license and insurance • Detail-oriented, organized, and able to work in a fast-paced environment • Excellent customer service skills • Computer literacy to perform job duties
Responsibilities:
Must be willing and able to work all locations and work a varied schedule to accommodate the needs of CCHC and our patients.
Experience with Continuous Quality Improvement (CQI) tracking and documentation. Familiarity with the Vaccines for Children (VFC) program.
Direct Supervisor: Reports to Director of Nursing and the CMO and the guidance of medical providers.
Summary: Under the supervision of the Director of Nursing and the CMO and the guidance of medical providers, the LPN Care Coordinator will be responsible for monitoring and coordinating the patients identified as needing care management. This position will supervise some operations of the Care Coordination Team and oversee chronic care management patient care activities and the coordination of services to meet patients needs and preferences in the delivery of high-quality, high-value healthcare.
Responsibilities Include but are not limited to:
• Development and implementation of effective and efficient standards, protocols, and processes reports and benchmarks that support and further enhance care coordination, chronic care management, and integrated care and quality of healthcare services • Create, implement, and maintain documented workflows while actively engaging in process analysis activities and driving process improvement for the care coordination team • Supervise Care Coordination Team to achieve optimal outcomes in patient care • Identify patients for care management by provider referral or using multiple diagnostic criteria or complexity of care requiring monitoring and assistance or via generated patient registries • Managed Care Organizations, E.R. & hospitalization lists, behavioral health, or nursing staff • Conduct timely patient outreach, engagement activities via telephone, direct mailing, or face-to-face for new and established patients to schedule appointments as needed for care planning, etc. • Track, monitor, and schedule follow-up appointments for patients recently discharged from the hospital or E.R. • Engage patients & providers in goal setting and establish the care planning process • Create, monitor, follow up, and share completed care plans as needed • Ensure that documentation is completed in EHR • Provide timely updates to providers when encountering barriers or request care conferences to assist with identifying problems encountered in reaching goals and provide feedback on progress as well • Assist patients with transitions to care, navigating healthcare services, and linkage to community resources in collaboration with the care team • Regularly collaborate, coordinate, and communicate with care team members to resolve any outstanding patient care-related items, i.e., care gaps, outstanding referrals, patient paperwork, etc. • Completes and submits data collection and reporting for specific clinical quality measures • Assist with closing the loop on outstanding referrals, lab results, patient documents, and consult reports by following up with patients, specialty providers, hospitals, health plans, community agencies, etc. • Acts as a resource to the care team and other staff members on the collection and management of population health data, patient outreach, tracking of patient progress, and generation of reports • Monitors clinical quality measure outcomes and identifies opportunities for improvement • Produce, maintain, and input timely, accurate, and thorough documentation of all communication with patients within the EHR • Maintain medical records by adhering to HIPAA guidelines when handling patient information and sensitive documents • Implement and maintain department processes for tracking all outreach efforts made, i.e., appointment scheduling • Timely and accurate completion of all care coordination tasks and assignments by deadlines • Maintain professionalism always when communicating with patients, staff members, and external agencies • Adhere to all policies, procedures, and protocols of the agency and department procedures • Participate in Patient-Centered Medical Home (PCMH) and quality improvement (QI) related committees and activities • Participate in clinical supervision • Participate in chart audits as needed • Attend meetings and trainings as scheduled • Participate in clinical and administrative huddles as assigned • Triage, provide direct care within scope of licensing, RX refills • Develop and implement workflows and KPIs • Develop and implement systems • Develop and implement policies and procedures as needed • Perform other duties as assigned
Employee Benefits:
• Blue Cross Blue Shield Medical Insurance • Blue Cross Blue Shield Dental and Vision Insurance • Supplemental Benefits • Life Insurance Provided by the company