LPN Care Coordinator- Homecare

LPN position. Working with Homecare patient base. Company equipment. Mileage reimbursement.

The Care Coordinator (LPN)

• Coordinates care and services within care managed population.

• Collects patient/family data to assist in identifying individualized care management needs.

• Implements plan of care interventions as identified by the Care Team and communicates with clerical and clinical support staff to coordinate activities to meet care needs using evidence-based protocols.

• Works with Care Team to identify individual care management needs. Huddles daily with Care Team for pre/post-visit planning to identify those patients who need close follow up, resources, additional education, and support.

• Documents needed interventions on providers schedule ie necessary labs, patients in poor control or who may need intensive education in-house or through referral.

• Coordinates plan of care and services, directing liaison activities to appropriately integrate the patient into the health care continuum.

• Monitors plans of care/pathways/practice guidelines to ensure that expected patient outcomes are achieved within appropriate time frames and utilizing effective resources.

• Facilitates Interdisciplinary Team Meetings. Provides feedback to the health care team verbally or via chart entries related to the patients progress toward reaching expected outcomes or about barriers to the plan. Coordinates changes to the plan as necessary.

• Documentation in the medical record is completed in the appropriate time frame and accurately reflects the plan of care and care management interventions planned or completed. Facilitates physician documentation of data that accurately reflects the patients condition, co-morbidities, treatment and procedures that support the most appropriate status.

• Facilitates an Interdisciplinary Approach to patient care.

• Facilitates continuity of care using multidisciplinary collaboration and coordination of appropriate health care services and community resources across the care continuum.

• Maintains effective communications with all disciplines.

• Prioritizes patients with chronic diseases/ outlier patients for appointments and/or forwards list to appointment desk to schedule patients. Conducts follow-up with identified patients: those with inconsistent follow up, recent hospitalization or ED visits, or those identified as having significant barriers to self-management or care coordination.

• Coordinates and manages all care transitions with a focus on comprehensive, accurate, and effective communication.

• Supports patient/ caregiver self-management and behavior change using motivational interviewing and coaching.

• Engages and empowers patient/ caregiver as an active participant in disease/ condition management.

• Determines readiness/ willingness to change based on protocols and partners with patient/ caregiver/ care team in identifying goals, plan of action.

• Identifies and tracks patient/ caregiver capacity for and confidence in self-care.

• Supports patient/ caregiver in adopting healthy behaviors and promotes lifestyle changes.

• Advocates for the patient and family throughout the entire episode of care.

• Provides focused, individualized patient/ caregiver education using evidenced based content and self - monitoring tools with teach back to ensure understanding.

• Assists patients/families with benefits/resources management. Communicates with patients/families to ensure understanding of third-party payer guidelines and financial implications of care plans. Maintains and updates community resources. Provides these to patients when appropriate, following up on referrals.

• Participates in department and system performance improvement initiatives.

• Uses protocols to evaluate the effect of care coordination and interventions on quality outcomes.

• Performs concurrent medical record reviews in assigned area. Reviews and tracks relevant patient data in accordance with accepted Disease Guidelines. Runs outlier reports for ongoing chronic care patients. Using protocols and approved guidelines, evaluates the effect of care management on quality outcomes and fiscal parameters.

• Documents utilization review in accordance with departmental guidelines. (Database/Disease registry management).

• Actively participates in quality improvement projects.

Education: Graduate of an accredited school of practical nursing.

Experience: 5 years of recent experience in a physician practice or clinic.

Licensure, certification, and/or registration: Current license to practice practical nursing (LPN) in the state of Virginia. AHA BLS-HCP required in practices where the Care Coordinator provides direct patient care. Case Management or Care Coordination Certification required within one year of hire.

Other Minimum Qualifications: Must demonstrate knowledge and competency in the following areas: positive interpersonal oral communication skills; effective written communication skills; analytic skills; team player; courteous; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability; willingness to work as an integral member of a multi-skilled team. Also demonstrate knowledge and competency in computer literacy; community and system resources; effective interpersonal relations; analysis and research methods. Must possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care.

This job description is only meant to be a representative summary of the major responsibilities and accountabilities performed by the incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Recruiter:

Recruiter Email:

For more information, contact the HR Service Center at 1-800-599-2537.

Carilion Clinic is an Equal Opportunity Employer: We provide equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, national origin, age (40 or older), disability, genetic information, or veterans status. Carilion is a Drug-Free Workplace. For more information or for individuals with disabilities needing special assistance with our online application process contact Carilion HR Service Center at 800-599-2537, 8:00 a.m. to 4:30 p.m., Monday through Friday.

For more information on E-Verify: https://www.carilionclinic.org/eoe-e-verify-and-right-work-policies

Carilion understands the importance of prioritizing your well-being to help you develop and thrive. That's why we offer a well-rounded benefits package, and many perks and well-being resources to help you live a happy, healthy life - at work and when you're away.

When you make your tomorrow with us, we'll enhance your potential to realize the best in yourself.Below are benefits available to you when you join Carilion:

• Comprehensive Medical, Dental, & Vision Benefits
• Employer Funded Pension Plan, vested after five years (Voluntary 403B)
• Paid Time Off (accrued from day one)
• Onsite fitness studios and discounts to our Carilion Wellness centers
• Access to our health and wellness app, Virgin Pulse
• Discounts on childcare
• Continued education and training

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