LPN Care Coach - Remote

CircleLink Health

7h • Remote

About The Position

CircleLink Health® is a company of passionate clinicians, technologists and business people tackling the $600B problem of preventable chronic condition complications. Our mission is to accelerate the shift to preventative care (from status quo reactive care) through our world-class preventative care platform.
As a Care Coach you will work remotely for 20-25 hours per week with a team of nurses to manage patients with chronic conditions enrolled in Medicare’s Chronic Care Management program.

Requirements

• Fluent in English.
• Meet communication skills, must be self-directed, able to work independently with little supervision while meeting performance metrics for case completion
• Strong passion for nursing of Medicare patients
• Strong communication: all messages and emails from staff must be acknowledged and responded to within 24–48 hours.
• Your caseload will consist of at least 40 patients but could be more.
• Excellent organizational and time management skills.
• Strong critical thinking and problem-solving skills.
• Commitment to work 20-25 hours, 3 days a week.
• Availability to make calls between 9-6 pm, EST.
• LPN needs a STRONG internet-connected computer. CLHealth does NOT provide computers.
• Current, unrestricted Compact LPN license--please visit www.nursys.com to find your license # and state
• Proficiency with electronic health records and web-based applications
• At least 5+ years' experience as a Licensed Practical Nurse

Nice To Haves

• Case Management or Chronic Disease Management experience
• Case Management Certification
• Certified Diabetes Educator
• Transitional Care Management experience
• Experience with Motivational Interviewing or other behavior change communication techniques

Responsibilities

• Educating patients on self-management skills and goal setting. Chronic conditions include: Diabetes, CHF, COPD/Asthma, Hypertension, CAD, Ischemic Heart Disease, Anxiety, Depression.
• Implement and improve the Plan of Care by updating medications, appointments due, record biometrics, vital signs, and care coaching provided.
• Utilize Motivational Interviewing or other behavior change techniques to coach and assist the patient with self-management.
• Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions, including medication reconciliation, medication adherence, identify red flags, address barriers, encourage follow-up care, how and when to seek appropriate level of care.
• Reduce care gaps by encouraging or assisting with preventive care, and chronic care management, i.e. annual well visits, follow up visits, medication management, pre-visit labs, diagnostic tests due, preventive cancer screens.
• Connect the patient with community resources as needed, including transportation, personal care needs, homemaker or chore services, social services, etc.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: No Education Listed