Chronic Care Coordinator, LPN

AllCare Health•Grants Pass, OR

7d•$34 - $37•Hybrid

About The Position

The Chronic Care Coordinator, LPN works in AllCare Health’s Population Health Department to deliver evidence-based wellness promotion and self-care management solutions to Medicaid, Medicare, and dual-eligible members of all ages who have chronic diseases or conditions. The position assesses members’ needs, develops and implements individualized care and case management plans, coordinates services and resources, and evaluates progress toward care goals. It advocates for members and collaborates with interdisciplinary care teams, providers, community agencies, and other relevant sources to support members’ ability to manage chronic illness and access appropriate care. The role maintains a caseload of high-risk or high-cost members with designated chronic conditions, provides condition-specific education, documents member interactions and outcomes, and coordinates care for Dual Special Needs Plan members in accordance with the Special Needs Model of Care. It participates in required trainings, audits, quality initiatives, and team meetings, and may precept new employees. The position receives clinical supervision from an assigned clinician, with supervision needs evaluated based on clinical experience and performance. It has no on-call or supervisory responsibilities. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m., with a one-hour unpaid lunch and two paid 15-minute breaks, for 40 hours per week. The employee may work onsite, from a home office, and travel as needed. Local travel may require use of a personal vehicle, subject to mileage reimbursement. The employee must maintain patient confidentiality and privacy in accordance with company policy and HIPAA requirements.

Requirements

Associate’s degree from a two-year college or technical school.
One to two years of related experience and/or training working with underserved populations, with demonstrated experience working with diverse populations in community settings.
Two to four years of related experience and/or training in case management, care coordination, managed care, homecare coordination, or as a registered Clinical Social Work Associate (CSWA).
Valid Oregon LPN license.
Valid Oregon driver’s license and vehicle insurance.
Current Basic Life Support (BLS) certification, or willingness to obtain certification within 90 days of hire.
Current Verbal De-escalation (CPI) certification, or willingness to obtain certification within 90 days of hire.
Current Mental Health First Aid certification, or willingness to obtain certification within 90 days of hire.
Familiarity with the healthcare industry; strong organization, time-management, and computer skills, including Microsoft Outlook, Word, PowerPoint, and Excel.
Knowledge of and compliance with HIPAA regulations; ability to locate and synthesize information and identify and implement improvements.
Knowledge of customer service, service recovery, phone customer service, and multi-line call center practices; ability to interact professionally with upset customers.
Knowledge of how implicit bias, personal identity, power, and privilege affect individuals, organizations, and systems; knowledge of trauma’s impact and paths to recovery; ability to recognize trauma and avoid retraumatization.
Ability to communicate professionally, collaborate with diverse multidisciplinary teams, prioritize competing work, meet deadlines, adapt to change and ambiguity, solve problems, manage stress, and exercise sound independent judgment.
Ability to work effectively and empathetically with people with mental illness and people from diverse backgrounds and experiences, while maintaining professionalism, confidentiality, and cultural awareness.
Ability to read and interpret documents, write routine reports and correspondence, and speak effectively before groups.
Ability to perform basic mathematical calculations and interpret bar graphs.
Ability to use computer systems for email, document composition, database entry, presentations, downloading forms, and data preservation or backup.
Ability to solve practical problems and interpret written, oral, diagrammatic, or schedule-based instructions.
Ability to occasionally lift or move up to 55 pounds and perform the physical activities described for the role.
Ability to work onsite, from a home office, and travel as needed.

Nice To Haves

Certified Case Manager (CCM) certification, or successful completion of the certification within two years of employment.
Bilingual English/Spanish skills; bilingual ability in another language, including American Sign Language, is also encouraged.
Relevant lived, volunteer, or professional experience, or a combination of experience and education, may be considered toward performing the essential duties.

Responsibilities

Assess, plan, implement, coordinate, and request services needed to meet members’ healthcare needs.
Advocate for members and facilitate collaboration with the interdisciplinary care team to help members develop knowledge and self-reliance in managing chronic illness.
Establish and document care objectives, goals, and actions, including reevaluating individualized care plans.
Interpret regulatory requirements related to care coordination and case management and coordinate processes to support compliance.
Conduct thorough assessments to identify members’ individual needs and develop comprehensive case management plans, adjusting them as necessary.
Implement and document interventions, activities, and tasks that support established goals.
Organize, integrate, update, modify, and document resources needed to accomplish care management goals.
Gather information from relevant sources, evaluate plan effectiveness and outcomes, and modify plans as necessary.
Deliver condition-specific education according to standards of care and clinical practice guidelines.
Document the full range of patient interactions, from disease-specific assessments through completion of goals.
Participate regularly in interdisciplinary care team meetings about complicated cases.
Coordinate with healthcare providers and community agencies to secure appropriate resources for members.
Maintain a caseload of high-risk or high-cost members with designated chronic conditions in accordance with department policy.
Assess members’ learning styles and develop teaching programs appropriate to their reading and comprehension skills.
Help members select actions that will complete goals and objectives in a timely manner.
Collaborate with care providers to ensure access to services and follow up on referrals.
Assist with department quality initiatives as needed.
Coordinate care for Dual Special Needs Plan members in compliance with the Special Needs Model of Care.
Prepare for and participate in required DSNP trainings, education, and member audits, as well as initial, annual, and ongoing trainings.
Act as a preceptor during onboarding of new employees.
Maintain punctual, regular, and predictable attendance; collaborate in a team environment; take direction from care coordination leaders; and complete required training.
Perform other duties as assigned.
Maintain patient confidentiality and privacy in accordance with company policy and HIPAA requirements.