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LPN Care Coach
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Full-time
- 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.
- 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.
- 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.
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