Care Coordinator - LPN - Infectious Disease

Carilion Clinic•Roanoke, VA

17h•Onsite

About The Position

The LPN Care Coordinator provides care management for specific patient populations, utilizing clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes. This role promotes cost-effective care by minimizing fragmentation, maximizing coordination and facilitating patient/family movement through the system. The Care Coordinator applies protocols when appropriate and facilitates referrals, providing linkages to health and wellness resources across the health care continuum, and promotes interdisciplinary collaboration and teamwork to progress the plan of care. Key responsibilities include coordinating care and services within the managed population, collecting patient/family data to identify individualized care management needs, and implementing plan of care interventions as identified by the Care Team. The coordinator communicates with clerical and clinical support staff to coordinate activities using evidence-based protocols and huddles daily with the Care Team for pre/post-visit planning. Direct clinical support during clinic visits involves rooming patients, obtaining and documenting vital signs, reconciling medications, reviewing care gaps, and preparing patients for provider evaluation. The role also includes documenting needed interventions, administering immunizations, monitoring plans of care, facilitating Interdisciplinary Team Meetings, and providing feedback to the healthcare team. Documentation in the medical record must be timely and accurate. The Care Coordinator facilitates physician documentation, promotes an Interdisciplinary Approach to patient care, and ensures continuity of care using multidisciplinary collaboration and community resources. They prioritize patients for appointments, conduct follow-ups for identified patients, and manage care transitions with effective communication. The coordinator supports patient/caregiver self-management and behavior change using motivational interviewing and coaching, empowering them as active participants in disease/condition management. This includes determining readiness to change, identifying goals, tracking self-care capacity, and promoting healthy behaviors. The role advocates for the patient and family, provides individualized patient/caregiver education, and assists with benefits/resources management. They maintain and update community resources, participate in department and system performance improvement initiatives, and use protocols to evaluate the effect of care coordination on quality outcomes. Additional duties include performing concurrent medical record reviews, tracking relevant patient data, running outlier reports, evaluating care management effects on fiscal parameters, and documenting utilization review.

Requirements

Graduate of an accredited school of practical nursing.
5 years of recent experience in a physician practice or clinic.
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.
Demonstrate knowledge and competency in positive interpersonal oral communication skills.
Demonstrate knowledge and competency in effective written communication skills.
Demonstrate knowledge and competency in analytic skills.
Demonstrate knowledge and competency as a team player.
Demonstrate knowledge and competency in being courteous.
Demonstrate knowledge and competency in ability to resolve complaints/problems.
Demonstrate knowledge and competency in customer-focused philosophy of service delivery.
Demonstrate knowledge and competency in computer literacy.
Demonstrate knowledge and competency in community and system resources.
Demonstrate knowledge and competency in effective interpersonal relations.
Demonstrate knowledge and competency in analysis and research methods.
Possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care.

Responsibilities

Provides care management for specific patient populations, utilizing clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes.
Promotes cost-effective care by minimizing fragmentation, maximizing coordination and facilitating patient/family movement through the system.
Applies protocols when appropriate and facilitates referrals, providing linkages to health and wellness resources across the health care continuum.
Promotes interdisciplinary collaboration and teamwork to progress the plan of care.
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.
Provides direct clinical support during clinic visits, including rooming patients, obtaining and documenting vital signs, reconciling medications, reviewing care gaps, and preparing patients for provider evaluation to support efficient, coordinated care.
Documents needed interventions on providers schedule ie necessary labs, patients in poor control or who may need intensive education in-house or through referral.
Administers immunizations per provider order and evidence‑based protocols, including patient screening, education, consent, documentation, and monitoring for adverse reactions, reinforcing preventive care and population health initiatives.
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.
Completes documentation in the medical record 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 community resources 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.
Evaluates the effect of care management on quality outcomes and fiscal parameters using protocols and approved guidelines.
Documents utilization review in accordance with departmental guidelines (Database/Disease registry management).
Actively participates in quality improvement projects.