Care Coordinator​/LPN

Overview

Job Title:

LPN/Care Coordinator

Pay Range: $22 - $33 per hour.

Department:
Clinical

About TCA Health, a Federally Qualified Health Center located on Chicago's far south side has been a provider of innovative, accessible, and quality primary care, dental, behavioral health services and more to Chicagoland's underserved communities for over 50 years!

The culture at TCA Health is one of service and commitment. Our team of dedicated professionals is the reason why TCA Health continues to be one of Chicago’s leading Federally Qualified Healthcare Centers.

TCA VALUES

• Compassion:
  We are kind, considerate, and caring.
• Accountability:
  We take ownership for each person’s experiences.
• Respect:
  We treat each person with dignity.
• Excellence:
  We seek the highest level of performance in all we do.
• Stewardship:
  We strive for racial and health equity, diversity, and inclusion by delivering quality health care and access for all.

The Care Coordinator/LPN will be responsible for monitoring and coordinating population- health management activities at one or more health center locations. The primary function of this position will be to work in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver to promote timely access to appropriate care, increase utilization of preventative care, reduce emergency room utilization and hospital readmissions, increase comprehension through culturally and linguistically appropriate education, promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver.

Using a team-based approach, the care coordinator will act as a resource to patients and health care staff to ensure patients receive all the care and services they require. Care Coordinators must be proactive, well-organized, present a friendly demeanor and function well in a fast-paced clinic environment. This person may be assigned to School Based Health Activities as well to assist in transitions of care for students leaving the umbrella of school-based health care into community healthcare.

They will ensure that students have the information and resources for continuity and management of their condition into the next setting.

• Identify patients for care coordination via generating patient registries, MCO care gap lists, Medical Home Network (MHN) portal, etc.
• Conduct timely patient outreach/engagement and follow up activities, via telephone, direct mailing, face-to-face and/or electronically, to new and established patients and to schedule coordinate appointments as needed.
• Track, monitor, and schedule follow-up appointments for patients recently discharged from the hospital or ER; collaborate with care team for patient needs.
• Assist patients in collaboration with care team, with transitions to care, navigating health care services and linkage to community resources and support.
• Regularly collaborate, coordinate, and communicate with care team member(s) to resolve outstanding patient care related items (care gaps; outstanding referrals, follow up paperwork etc.)
• Assist with data collection and reporting for targeted clinical quality measures.
• Assist with closing the loop on outstanding referrals, diagnostic results (i.e. labs, x-rays, etc.) patient documents and consult reports by following up with patients, specialty providers, hospitals, health plans, community agencies, etc.
• Provide patient education resources to assist the patient with self-management needs.
• Serve as a resource to the care team and other staff members on the collection and management of population data, patient outreach, tracking of patient progress, and generation of reports.
• Collaborates with nursing staff (RN’s/LPN’s) to identify and refer appropriate patients for complex care management.
• Monitors clinical quality measure outcomes and identifies opportunities for improvement in collaboration with Director of Clinical Quality.
• Produce, maintain and input timely, accurate, and thorough documentation of all communication directly with and on behalf of patients with the EHR; including…