LPN Care Coordinator

Description

POSITION SUMMARY

The LPN Care Coordinator serves as a liaison between the patient and the providers. LPN Care Coordinators are responsible to perform regular updates on patient well-being, help develop treatment plans, communicate with patients about their diagnoses and care plan, evaluate the patient’s recovery process. LPN Care Coordinators ensure that patients have access to medical resources. Their primary goal is to improve patient outcomes by ensuring that patients understand their condition and treatment plan.

REPORTING RELATIONSHIPS

This position reports to the Nurse Manager. The position works directly with clinical staff, residents, physicians, providers and practice managers.

DUTIES & ESSENTIAL JOB FUNCTIONS

• Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that have experienced any transition from a healthcare facility (i.e. ED, hospital, rehabilitation facility, SNF, etc.) to home including follow-up phone calls and the coordination of follow-up visits with the primary care Provider-Team to include:
• Obtaining daily list of patients admitted and discharged from the hospital, using My Patient Your Patient Software, and meeting with GHP Case Manager to determine accountability for patient TOC management. If the GHP Case Manager is absent, the LPN CC is responsible for completion of all TOC calls and related patient management and for communicating daily with the GHP Case Manager replacement to review TOC data for GHP and Medicare fee for service patients
• Call assigned transitional care patients within 48 hours of discharge to collect and document information and data from the patients about symptoms, functional status, safety, and support at home, current complaint/s, and medication reconciliation
• Arrange follow-up visits for transitional care patients with the Primary Care Provider-Team within 2-7 days post discharge based on patient needs (within 2-3 days if symptoms not managed, functional status concerns, safety issues, no support at home, medication non-reconciliation)
• Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that are medium risk, rising risk or high risk and Rising Risk Registry of Patients to include:
• Run the high-risk stratification tool monthly, reviewing the list with the lead panel Provider to identify/verify the list high risk panel patients, and then adding high risk patients to Care Coordinators’ high-risk registry (list excludes patients managed by GHP Case Manager)
• Coordinate care of at least 30 high risk patients and rising risk patients within the assigned panel (excludes patients managed by the GHP Care Manager)
• Obtain and document information and data from the patients about vital signs, symptoms, functional status, safety and support at home, socioeconomic status, current complaint/s, and medication reconciliation
• Review and document the education plan with patients to include use TWC-specific handouts that address basic disease information, symptom management, functional status concerns, safety issues, and medication information and administration information
• Assist patients with self-management goal setting to improve healthy behaviors and manage chronic illnesses or conditions
• Bill the CC charges daily per procedure
• Facilitate the weekly Huddle at MVP
• Attend monthly ACO meetings
• Always manage at least 30 TOC cases
• Participation in rotation of extended access hours including late nights, weekends and holidays
• Cross coverage of other locations and service lines for continued support and access for patients
• Cross coverage of other locations and service lines for continued support and access for patients
• Participation in extended access hours including late nights, weekends and holidays
• Cross coverage of satellite locations for continue support and access for patients
• MVP Health Center – 1 late night a week (12pm-8pm)
• Understanding of multiple insurance dynamics including copays, coverage, navigation to assist the patient with medication or services
• Commitment of outreach and engaging a minimal of 30 patients per month who are enrolled in TWCCH’s Chronic Care Management Program
• Daily reconciliation on hospital admissions and discharges for high risk patients for timely coordination of next steps to prevent readmission, crisis, and to keep care team up to date on patient status
• Maintaining required certifications and training to be compliant with the HRSA credentialing regulations.
• Completing and staying up to date on yearly compet