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LPN - Care Navigator - Full Time
4 months ago
General Summary:
The Clinical Care Coordinator, ensures coordination and continuity of care through effective transitions of care management as patients move in and out of the acute care environment and Post- Acute settings. Providing education, discharge planning to ensure continuity of care across care transitions.
This position requires contact with the patients and their care givers to perform barrier assessments, offer solutions to improve patient care, serve as an advocate to identify life goals, and provide input in the treatment planning process. The Clinical Care Coordinator will also ensure the coordination and communication of a patient's treatment plan and general status to all providers and care givers during the continuum of care. This position will assist patients in education of finding appropriate care by connecting patients with the appropriate resources. This can occur by phone, email or in-person contact.
Principal Duties & Responsibilities:
Example of Essential Duties:
* Will complete daily post-discharge calls to satisfy the TCM billing requirements.
* Complete weekly "Care Calls" to identified patients who are at risk for rehospitalization as directed.
* Documents all calls by entering data into a computer terminal database.
* Anticipates customer needs; looks ahead and is prepared to assist in a proactive manner.
* Effectively operates computerized telephone equipment.
* Compiles, maintains, and processes records, data, documentation and reports regarding calls, contacts and actions.
* May assist with or perform research to determine solutions to problems affecting customers.
* Assures that customer is satisfied and documents call appropriately. Follow up on all calls as necessary.
* Initiates problem solving and pursues continuous improvement in customer satisfaction.
* Diffuses emotion of aggravated callers by creating a partnership with the customer.
* Maintains strictest confidentiality.
* Must be able to multi task; speak clearly and professionally over the telephone.
* Serves as an educational resource regarding hospice and home care for providers, patients, and care givers
* Educate the patient and the care giver on the importance of care in the continuum; this will enable providers to communicate with each other, identifying gaps in care,
reduce hospital readmission, improved outcomes and patient satisfaction
* Is accessible via phone and email to continuum partners, providers, peers, and supervisor during working hours. Flexibility in work schedule to accommodate needs of patient and care givers
* When necessary or as directed, travel to patient locations such as hospital, skilled nursing facility, and in the home to assess patient needs and status
* Monitor that appropriate home care, hospice and other ancillary services are in place and are being delivered as directed by the care team
* Call post discharge high-risk patients to decrease potential for re-hospitalization.
* Performs other duties as assigned.
Other Essential Duties May Include (but are not limited to):
The above list of duties is intended to describe the general nature and level of work performed by people assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the people so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct and control the work of employees under his/her supervision.
Knowledge, Skills & Abilities Required:
Minimum Qualifications:
* Must have active LPN licensure in Ohio and Michigan with 3 years of applicable nursing experience
* Relevant experience in working with diverse populations
* Must have exceptional problem-solving, critical-thinking, organizational, interpersonal, and written/verbal communication skills.
* Ability to work in self-directed environment with attention to detail and follow-through.
* Must be able to function effectively in a critical care environment.
* Must be able to establish priorities and communicate and respond to inquiries.
* Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
* Ability to work effectively with numerous department and administrative levels.
* Willingness to comply fully with all organizational and departmental policies and procedures.
* Consistently arrives at work, in professional attire, on time and completes all tasks within established time frame.
* Seeks appropriate tasks when primary tasks are completed and assists co-workers as needed.
* Demonstrates adaptability to expanded roles.
* Adheres to all clinic policies and procedures.
