LPN Care Coordinator

Benefits:401(k)401(k) matchingDental insuranceHealth insurancePaid time offVision insuranceJOB DESCRIPTIONLPN Care CoordinatorAlliance Family Health Center, Inc.BASIC FUNCTION:The LPN Care Coordinator, in alignment with the goals of Alliance Family Health Center and PCMH (Patient Centered Medical Home), is responsible for activities including disease management, referral coordination, hospital follow up for high-risk patients, and integration of evidence-based clinical and prevention guidelines into care. The Care Coordinator will promote team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician.JOB DUTIES:Use data systems to monitor gaps in care and oversee scheduling of patient appointments for needed services.Coordinates continuity of care with external healthcare organizations, including facilitating hospital follow-up and referrals to a specialty care provider or community resources.Proactively reach out to high-risk patients, obtain consent, and manage patient care.Conduct monthly touch points with patients to evaluate goal attainment and health management; celebrate successes and provide suggestions about how to overcome barriers.Track referrals and open orders in conjunction with AFHC Referral Specialist.Perform medication management, including reconciling discharge medications with ongoing medication regimen and develop a patient-directed self-management strategy for compliance.Acts as patient and care team liaison to assist all patients through the healthcare system by engaging as a patient advocate and navigator.Supports patient self-management of disease and behavior modification interventions.Develop and maintain positive relationships with patients by providing ongoing support for the patient and their family.Facilitates discussion and promotes clear communication amongst care teams by ensuring adherence of patient care plans.Participates in all care team activities such as provider meetings, team huddles, and quality improvement initiatives.Assesses patient health, education, and psychosocial needs using standardized assessment tools.Provides health and disease education in a meaningful and relevant manner.Prepares necessary reports, exam notes, laboratory results and other related documents prior to patient appointments.Maintains required documentation for all care management activities in EHR; maintaining up to date patient records with information on specialist consults, hospitalizations, and ER visits.In coordination with AFHC BHIC develop and implement standards and workflows for PCMH recognition.In coordination with AFHC BHIC obtain and maintain PCMH recognition.Demonstrate customer focused interpersonal skills to interact in an effective manner with practitioners, care teams, community agencies, patients, and families with diverse opinions, values, religious, and cultural ideals.Demonstrate ability to develop positive, longitudinal relationships and set appropriate boundaries with patients and families.Works under the guidance of the AFHC colleague handbookMaintain patient confidentiality by following HIPAA and Notice of Privacy Practices.HEALTH CARING STANDARDS:Greet customers, visitors, and Colleagues immediately with a smile, warm greeting, and introduction, calling them by name if possible.Exceed the expected and anticipate the unexpected by asking, "Is there anything else I or a fellow colleague can do for you?"Always provide a comforting, timely, caring departure or discharge, and always say thanks for allowing us to serve.Integrity, openness and fairness in all you doTeamworkPride in Health CenterIndividual creativity and InnovationCompassion and caringMaintain department and hospital standards and policies.AGE APPROPRIATE CARE:Colleague has been instructed in providing customer service and on interacting with age groups as related to the department's general client population: including use of appropriate interventions, communication and skills to match the age and/or abilities ofthe patient/family.MACHINES, TOOLS & EQUIPMENT USED:Office equipment (copy machine, fax machine, telephone), Athena EHR, Computer SoftwareAED, Sterilizer, BP cuffs, Otoscope, glucose monitor, other medical equipment as appropriate.EDUCATION, TRAINING & EXPERIENCE:Minimum two years' experience in a clinical settingGraduate of Accredited Licensed Practical/ Vocational Nursing Program or Registered Nursing ProgramExperience in care coordination, patient navigation, or population health required.Active LPN/RN license required.Current CPR certification required.SKILLS REQUIRED:Medical terminology and pharmacology required.Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, and health risk assessments.Ability to manage complex clinical issues utilizing assessment tools and protocols.Focus on detail and self-motivated with ability to work with little supervision.Problem solving, conflict resolution, critical analysis skills.Proficient in Microsoft OfficeExcellent organizational skillsExperience with computer technologyDetail oriented and self-motivatedExcellent customer service skillsPHYSICAL REQUIREMENTS:Normal space, ventilation, and noise levelsMust possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.Must be able to get up and down out of chair frequently throughout the shift.Must be able to lift 40 lbs.Must be able to verbalize well and possess manual dexterity to write legibly.RESPONSIBLE TO:Behavioral Health Integration CoordinatorChief Operations and Compliance OfficerThis description is intended to describe the essential job duties and the essential requirements for the performance of this job.