LPN Care Coordinator

Community Health Centers of Greater Dayton•Dayton, OH

11h•Hybrid

About The Position

The LPN Care Coordinator functions, in collaboration and ongoing partnership with chronically ill or ‘high risk’ patients, including Mental Health patients with care management needs, and their family/caregiver(s), Primary Care Provider, and other staff, Specialty providers, as well as other community resources in a team approach to: Promote timely access to appropriate care, Increase utilization of preventive care, Create and promote adherence to a care plan, developed in coordination with the patient, staff, primary care provider and family/caregiver(s) through Care Management, Create and update with patients, a Personalized Prevention Plan during RN-led Annual Wellness Visits, Reduce emergency room utilization and hospital readmissions with patients identified as high resource use in these areas, Enhances cost effectiveness by addressing care gaps and avoiding service duplication, Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care and referrals, Increase patient’s ability for self-management and shared decision-making, Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs, Increase comprehension through culturally and linguistically appropriate education.

Requirements

Licensed Practical Nurse with current, unrestricted license in the state of Ohio
Current CPR certification.

Nice To Haves

Ability to manage and prioritize multiple tasks
Working knowledge of EHR, Next Gen preferred
Proficient in Excel, Word and PowerPoint and ability to learn other computer programs.
Good organizational and self-management skills
Excellent verbal and written communications skills
Ability to communicate with a diverse range of people, from physicians to the patient population
Demonstrates knowledge of, and adherence to patient’s rights, confidentiality and HIPAA guidelines and regulations
Knowledge of local community health and social welfare resources preferred
Ability to relate well to people from diverse ethnic and cultural backgrounds
Demonstrates working knowledge of PCMH processes and guidelines preferred
Ability to travel to different site locations as necessary
Previous experience in Community Health Center, Care coordination and/or case management experience preferred.
Knowledge of NextGen EHR preferred
Knowledge of ICD-10 and CPT coding preferred

Responsibilities

Assess patient’s unmet health and social needs
Develop a care plan, with patient, family/caregiver(s) and providers
Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate needed changes and follow up plan(s)
Create ongoing process for patients and family/caregiver(s) to determine and request care coordination support they need or desire
Evaluate outcomes of care
Lead Annual Wellness Visits as auxiliary staff, creating and updating the patient’s Personalized Prevention Plan and other AWV documentation in the EHR
Identify gaps in care and implement methods to close gaps, including those attached to quality/value-based payments and bonuses
Assist in outreach campaigns related to patient engagement, quality initiatives, transitions of care, referrals, etc.
Identify high utilizers on transitions of care reporting and perform outreach and patient education, as well as evaluate appropriateness of care plan for patients
Educate patient and family/caregiver(s) about relevant community resources
Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan regarding transitions of care and referrals
Identify ‘high risk’ patients for Care Management utilizing available reports and recommendations by staff/providers
Appropriately, and routinely, document activities in the patient’s EHR and care plan
Attend Care Coordinator and other training courses, webinars, etc. to remain current on regulations, practices, etc.
Provide feedback to, and participate in QA PDSA’s and other quality initiatives/projects
Review and track patient outcomes through data systems, reporting, and dashboards
Perform other duties as assigned