Care Coordinator LPN

CUMBERLAND FAMILY MEDICAL CENTER IN•Lawrenceburg, KY

4d•Onsite

About The Position

Care Coordinator Family Care of the Bluegrass - Lawrenceburg is a mission-driven, patient-centered organization committed to providing comprehensive, high-quality health care to underserved populations. We strive to create a welcoming and inclusive environment that supports health equity and improves outcomes for our diverse community. Position Summary: The Care Coordinator serves as a key member of the clinical team, working collaboratively to support patients in navigating the healthcare system. This position is responsible for coordinating care across services, advocating for patients, and ensuring access to the resources needed for improved health outcomes. Cumberland Family Medical Center (CFMC) operates a Federally Qualified Health Center (FQHC) offering a wide range of health and social services at multiple sites throughout Kentucky. We seek employees who support our mission and who actively contribute to our service-driven environment by enhancing patient experience and improving productivity. CFMC offers compassionate care, uncompromising service and clinical excellence. We offer a collaborative environment with excellent benefits, wage/salary commensurate with experience and relevant work experience.

Requirements

Valid LPN license
CPR certification
Maintenance of required continuing education courses

Nice To Haves

Preferred associate’s degree in nursing or higher
Experience in medical office setting preferred

Responsibilities

Medicare Annual Wellness Exams
Chronic Care Management (CCM)/Principal Care Management (PCM)
Run report on Medicare patients eligible for wellness exam quarterly
Contact patients via phone or letter regularly to schedule appointment for exam
Perform wellness exam by Medicare guidelines using IMS template
Assist AWV, CCM, or PCM patient with community resources as needed
Run report on Medicare/Medicaid patients eligible for CCM/PCM services quarterly
Contact patients to offer CCM/PCM services
Facilitate appropriate paperwork for consent for CCM/PCM services
Utilize templates to document CCM/PCM services
Contact with CCM/PCM patient via phone/patient portal to discuss care plan, labs, etc.
Reviewing the current care plan and making changes as needed
Patient education on disease management upon provider request
Medication reconciliation
Hospital follow-up calls and documentation
Reviewing medical records and test results for AWV, CCM, or PCM patients
Generate daily huddle reports and distribute to clinical staff
Generate and work quality reports at least monthly
Utilize reporting system to generate HBA1C report weekly and contact patients with overdue or HBA1C greater than nine percent
Assist with WellCare Appointment Agendas
Contacting other providers regarding patient care
Add pop up notes in IMS for care gap services needed
Other duties as assigned by clinic provider with approval from Chief Nursing Officer