LPN Care Coordinator

Benefits

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

LPN Care Coordinator

Alliance Family Health Center, Inc.

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.

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 handbook

Maintain patient confidentiality by following HIPAA and Notice of Privacy Practices.

• 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 do
• Teamwork
• Pride in Health Center
• Individual creativity and Innovation
• Compassion and caring
• Maintain department and hospital standards and policies.

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 of the patient/family.

Office equipment…