Care Coordinator LPN

2 months ago

Yuma, United States VBCare Network LLC Full time
Job DescriptionJob DescriptionABC Network, a subsidiary of VBCare Network, is a Medicare ACO. Our service areas cover southern Arizona including Cochise, Pima, Pinal, and Yuma. The care coordinator LPN is a nursing professional responsible for coordinating care provided to eligible Medicare beneficiaries. This includes but is not limited to assessing medical and socioeconomic needs, care planning, patient education, resource management, coordinating clinical specialist and primary care appointments, insuring patient transportation patient reminders and visits, and ensuring effective communication between all healthcare professionals involved in the beneficiary’s care.

This position works under the direction and supervision of the Manager of the Care Management Service. The Care Coordinator LPN will work remotely approximately 80% but must be willing to work in the field which requires travel to our southern Arizona health centers sites or patient’s home will be necessary in the performance of the job duties.

Essential Job Duties
  1. Conduct comprehensive assessments of patients’ health status, including physical, psychological, and social aspects.
  2. Performs medication review or reconciliation as necessary or as directed.
  3. Monitor patient’s health status and response to treatment plans, adjusting as necessary.
  4. Develop, implement, and regularly update individualized care plans in collaboration with patients, their families, and other healthcare professionals. (LPN collaborates with RN for care plan development and updates.)
  5. Ensure care plans address all aspects of patient care, including chronic disease management, medication management, and social determinants of health (SDOH).
  6. Coordinate care among various healthcare providers and social services.
  7. Works with patients to coordinate appointments and services and manages a case load of beneficiaries as direct by care manager.
  8. Educate beneficiaries and their support systems about their chronic conditions, care plan interventions, and self-management strategies.
  9. Document patient specific needs in care plan.
  10. Maintain accurate and up-to-date medical records, documenting all patient interactions, care plans, and outcomes.
  11. Ensures patient is get follow-up care with their PCP after hospitalization and ER visits.
  12. Initiate text and phone call reminders.
  13. Send get well cards and other personalized notes to beneficiaries.
  14. Engages and activates the beneficiaries and their care giver in self-care management.
  15. Facilitates communication between physician and the patient and caregiver.
  16. Identifies and refers beneficiaries to appropriate community resources and support services.
  17. Monitor and evaluate the effectiveness of care coordination activities and make recommendations for improvement.
  18. Initiate transition of care directing community health workers (CHWs) to assist beneficiaries from hospital or skill nursing facility to home or skilled nursing facility to hospice.
  19. Provide guidance and support to CHWs in their roles.
  20. Arrange for assistive support as necessary.
  21. Coordinates the Medicare patient’s discharge planning with hospital staff.
  22. Set up and train beneficiaries on remote monitoring devices.
  23. Arranges for virtual consults as necessary.
  24. As directed, communicate with the beneficiaries’ PCPs.
  25. Advocates for the patient as necessary to assure beneficiary get their covered Medicare benefits and for patients’ needs and preferences within the healthcare continuum.
  26. Attends training courses and professional continuing education to stay up to date with clinical treatments for patients with multiple chronic conditions.
  27. Follows protocols and clinical guidelines under the supervision of the Medical Director.
  28. Participate in case reviews with the care manager and Medical Director.
  29. Must maintain patient confidentiality and be compliant with HIPAA regulations regarding the storage and transmission of e-PHI.
  30. Works closely with the multidisciplinary care team, including care managers, CHWs, and Medical Director.
Qualification and Experience
  1. Strong experience performing coordination of care duties for Medicare beneficiaries in a similar role at an ACO, hospital, or healthcare delivery system.
  2. Experience working with Arizona primary care and specialist providers.
  3. Associate degree and License Practical Nurse Certificate.
  4. Spanish-speaking desirable
  5. Must be an Arizona Licensed Nurse
  6. Must be an Arizona resident with a valid Arizona driver’s license and preferably live in Southern Arizona or Phoenix.
  7. Strong critical thinking and communication skills.
  8. Must have strong empathy for elderly patients with chronic conditions.
  9. Must be able to effectively collaborate with primary care teams and specialists.
  10. CPR and first aid certificate.
Physical Demands and Work Environment:
  • Will need to travel to our southern Arizona health centers sites or patient’s home will be necessary in the performance of the job duties.
  • Generally working remotely from home 80% of the time the other time on the field, including health center sites or patients’ homes.
  • Frequently required to stand and walk.
  • Frequently required to sit.
  • Computer work required and to continually utilize hand and finger dexterity.
  • Occasionally required to balance, bend, stoop, kneel or crawl
  • Continually required to talk or hear.
  • Continually utilize clinical nurse expertise and read clinical and medical information,
  • Ability to drive long distances.
  • Occasionally required to lift items up to 25 lbs.

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