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Care Coordinator
1 month ago
The LVN Health Coach is responsible for successfully supporting Disease Management/Chronic Care Program requirements for medical group/health plan members. The LVN Health Coach will interact and collaborate with multidisciplinary care teams, which include physicians, nurses, pharmacists, laboratory technologists, social workers, and other educators. li>Works with the PCP and clinic staff to identify patients with high risk diagnoses such as CHF, IHD, COPD/asthma and diabetes and ensures clinical guidelines are being followed Conducts Chronic Care Model visits and reviews the patient’s informal and formal support systems, focusing on what patients want to improve and educating them about their chronic disease Provide necessary coaching to reduce or eliminate behaviors that are considered high-risk Enters timely and accurate data into the electronic medical record to communicate patient needs and to ensure complete documentation of patient visits and phone calls. Tracks self-management goal outcomes and documents in electronic medical record Maintains current knowledge regarding CHF, IHD, COPD/asthma and diabetes as well as related treatments and complex medications Assists, initiates referrals, and coordinates transitions of car regarding hospitalization follow-up, palliative care, hospice, etc.Establishes a trusting relationship with identified patients, caregivers, clinic staff members and physicians Attends educational offerings to keep abreast of change and complies with licensing requirements, ensures all patient educational materials are up-to-date, and maintains knowledge of specialty and ancillary provider contract contents, to include exclusions and contract terms Conducts clinic one-on-one visits with Disease Management Chronic Care Program participants, utilizing the Chronic Care Model, to assess patient needs for DME, home health, value-added services and any other necessary resources.Collaborates with the nurse manager to recommend policies, procedures and standards which affect the care of the patient with high-risk chronic disease diagnoses such as CHF, IHD, COPD/asthma and diabetes
