Licensed Practical Nurse​/Medical Coordinator

Licensed Practical Nurse / Medical Home Coordinator

This position provides both direct and indirect patient care in a primary care office and works with care delivery providers to identify gaps in care, contact patients to schedule required care, and provide referral follow up. The Medical Home LPN provides pre‑visit planning for the practice's patient panel, coordinates messages through electronic portals, and assists in managing transitions of care. The Medical Home LPN will act as a clinical liaison to the physician care plan and actively communicate with patients.

The LPN participates in process improvements, is knowledgeable of clinical goals and outcomes including patient satisfaction and engagement. Other job‑related duties may be assigned to meet the needs of the department. Must have strong skills in clinical care, customer service, communication, and teamwork. This role understands the needs of the organization and supports the mission, values, and management of Tri Health Physician Practices.

• Coordinates the primary care rooming process, relevant medical procedures, adult and pediatric patient care including immunizations, venipuncture, point of care testing, and performs retinal scan images.
• Follows scheduling decision tree, protocols and policies for clinical procedures and appropriate use of medical equipment.
• Provides accurate and complete documentation of all facets of care including clinical calls, patient rooming questions, completion of procedures, order entry, prescriptions and patient pharmacy, and workflows.
• Addresses messages in a timely manner and escalates issues as appropriate. Utilizes and monitors MyChart messaging to support patient communication.
• Participates as part of the patient centered medical home team during all patient visits by reviewing patient chart for clinical gaps in care. Assist with outreach campaigns and tactics to close gaps in care.
• Supports and completes pre‑visit planning and participates in daily huddles with the physician and care team.
• Embeds wellness and prevention by reminding patients of all screenings and immunizations due by the end of the year and informs physician of any potential barrier identified by the patient.
• Utilizes key quality and unitization metrics of value‑based programs for both wellness and chronic disease management. Demonstrates abilities in the Primary Care quality program including all protocols of well and chronic disease states.
• Identifies patients at risk for change in condition and increased utilization. Attends required population health training and education such as Lunch and Learns and other opportunities.
• Participates in the longitudinal care continuum of patients through completing post ED/post inpatient discharge outreach on identified risk patient group. Updates care team through documentation and works collaboratively with Complex Care RN, Social Worker, CHW, and Population Health Pharmacist.
• Provides basic community resources to patients with social determinants in health. Supports and provides education and patient coaching of both wellness and chronic disease management (e.g., Diabetes Education, Colon Cancer Screening). Supports facilitating follow‑up for post‑hospital care, chronic disease management, or specialty referral.

• Graduate of an approved technical, professional, or vocational program in Healthcare or equivalent experience accepted in lieu of degree.
• Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) certification.
• Medical office flow experience, especially clerical/front office tasks.
• Ability to make quick decisions based on well‑thought‑out consequences/results.
• Knowledge of EMR systems.
• Practice management software and medical coding/billing experience strongly encouraged.
• 3–4 years of clinical healthcare experience.

Mid‑Senior level

Full‑time

Health Care Provider

Hospitals and Health Care