LPN Care Coordinator, Embedded (Hyattsville, MD)

Ennoble Care • Hyattsville, MD

11h • Onsite

About The Position

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, and Georgia. Ennoble Care’s clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, “To Care is an Honor.” Join Ennoble Care today!
Position Summary:
The Embedded Care Coordinator (Licensed Practical Nurse) is an on-site clinical care coordination role embedded within skilled nursing and rehabilitation facilities. This position focuses on transitional care management (TCM), proactive patient monitoring, and close collaboration with Ennoble Care providers and facility staff to ensure continuity of care, timely interventions, and prevention of unnecessary hospitalizations and readmissions.
The Embedded Care Coordinator serves as a critical communication and coordination bridge between residents, families, facility staff, Ennoble Care providers, and the house calls division, supporting high-quality, patient-centered care during and after transitions.

Requirements

• Legally authorized to work in the United States
• Active Licensed Practical Nurse (LPN) license in good standing
• Minimum 1 year of experience in skilled nursing facilities, rehabilitation settings, long-term care, or transitional care
• Comfortable communicating throughout the day via Microsoft Teams, email, phone, and in person
• Working knowledge of healthcare terminology and care coordination principles
• Strong clinical assessment skills with the ability to identify and escalate changes in condition
• Experience with EMR systems and clinical documentation (e.g., Point Click Care - preferred)
• Excellent communication, organization, and time-management skills
• Ability to work independently while collaborating closely with multidisciplinary teams
• Ability to work on-site, full-time
• No on-call
• Daytime hours
• Seven (7) company-paid holidays annually
• Valid, unencumbered driver’s license
• Reliable personal vehicle
• Current auto insurance, with the ability to provide proof
• Please note, travel between facilities may be required
• Ability to pass a background check and drug screen

Nice To Haves

• Experience with EMR systems and clinical documentation (e.g., Point Click Care - preferred)

Responsibilities

• Coordinate care for patients residing in and rehabilitation facilities using Ennoble Care’s EMR
• Facilitate transitional care management, ensuring timely initiation of services with the house calls division upon discharge from facility
• Expedite time to first provider visit for newly transitioned patients
• Support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions
• Monitor patients with acute symptoms, initiate appropriate interventions, and escalate care as clinically indicated (including CCM-billable activities)
• Maintain a consistent and reliable daily on-site presence in assigned facilities
• Conduct routine and urgent vital sign collection as needed
• Perform regular, proactive patient check-ins to support care plans, follow-ups, and ensure clinical stability
• Identify changes in patient condition and promptly communicate concerns to the clinical team
• Serve as a key liaison between Ennoble Care providers, facility staff, residents, families, and the house calls team
• Collaborate closely with Ennoble Care providers within the skilled nursing facility or rehab setting
• Act as a communication bridge to ensure accurate, timely exchange of clinical information
• Provide timely and accurate clinical updates to providers to support informed decision-making
• Ability to convert 1 patient per week to Ennoble Care's House Calls program.
• Accurately document patient interactions, assessments, and care coordination activities in Ennoble Care’s EMR
• Perform chart reconciliation to ensure accuracy and continuity of clinical records between Ennoble and facility EMR
• Follow established workflows, documentation standards, and escalation protocols
• Contribute positively to team collaboration and foster strong partnerships with facility staff
• Support onboarding and training of new Embedded Care Coordinators
• Serve as a clinical mentor and resource for newly hired coordinators
• Promote best practices in transitional care, communication, and facility-based care coordination

Benefits

• Medical, Dental, Vision and supplementary benefits such as Life Insurance, Short Term and Long Term Disability, Flexible Spending Accounts for Medical and Dependent Care, Accident, Critical Illness, and Hospital Indemnity.
• Paid Time Off
• Paid Office Holidays
• Paid Sick Time
• 401(k) with up to 3% company match
• Referral Program
• Payactiv: pay-on-demand. Cash out earned money when and where you need it!

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed