LPN Care Coordinator, Embedded; Prince Georges County, MD Prince Georges County, MD

LPN Care Coordinator, Embedded (Prince Georges County, MD)

Prince Georges County, MD

About Us

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. Ennoble Care’s clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust.

About the Role

As an LPN Embedded Care Coordinator, you will work on‑site within one or more of our partnered skilled nursing and rehabilitation facilities in Prince George’s County, Maryland. Your primary focus will be transitional care management, attentive patient monitoring, and day‑to‑day collaboration with our clinical team and facility staff.

Required Qualifications

• Legally authorized to work in the United States of America
• Active, unrestricted LPN license in the state of Maryland
• Minimum 1 year of patient‑facing experience in a long‑term care, skilled nursing, or transitional care setting
• Comfortable communicating proactively throughout the day in person, by phone, via email, and through Microsoft Teams
• Solid working knowledge of healthcare terminology and care coordination principles
• Strong clinical assessment skills with the ability to identify and elevate changes in condition
• Experience with EMR systems and clinical documentation;
  Point Click Care experience preferred
• Proficient with Microsoft 365 including Excel, Outlook, Word, and Teams
• Excellent communication and interpersonal skills, with a solid foundation in organization, time management, and clinical documentation
• Capacity to work independently while collaborating closely with multidisciplinary teams
• Ability to work full‑time in an on‑site role based in the Prince George’s County, Maryland area
• Ability to pass background check and drug screen
• Transportation criteria:
  • Valid, unencumbered driver's license
  • Consistent and reliable transportation to fulfill the duties of this position
  • Current auto insurance, with the ability to provide proof

Note:

Travel between facilities may be required.

Key Responsibilities

Care Coordination & Transitional Care Management

• Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR
• Facilitate transitional care management, ensuring services with the House calls division are initiated immediately upon a patient's discharge from the hospital
• Expedite time to first provider visit for newly transitioned patients in accordance with established guidelines
• Monitor patients attentively, communicate changes in condition promptly to the provider, initiate appropriate interventions, and upscale care as clinically indicated, including CCM‑billable activities
• Consistently support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions
• Collaborate daily with providers and facility staff to ensure care plans are kept current and acted on

On‑Site Clinical Support

• Maintain a consistent and reliable daily on‑site presence in assigned facilities
• Build ongoing relationships with residents and their families, reinforcing trust and continuity of care over time
• Conduct routine and urgent vital sign collection as needed
• Perform regular patient check‑ins to support care plans, follow‑ups, and clinical stability
• Identify changes in patient condition and promptly communicate concerns to the clinical team
• Serve as a key liaison between Ennoble Care providers, facility staff, residents, families, and the House calls team
• Provide timely, accurate clinical updates to providers to support informed decision‑making
• Ability to convert two eligible patients per day to Ennoble Care's House calls program

Documentation & EMR Management

• Accurately document patient interactions, assessments, and care coordination activities in Ennoble Care’s EMR
• Perform chart reconciliation to ensure accuracy and continuity of clinical…