LPN Care Coordination Specialist

2 weeks ago


Phoenix, Arizona, United States VBCare Network LLC Full time
Position Overview: The LPN Care Coordination Specialist plays a vital role in managing care for eligible Medicare beneficiaries.

This position entails a comprehensive approach to assessing both medical and social needs, developing care strategies, and facilitating patient education. The specialist is responsible for coordinating appointments with clinical specialists and primary care providers, ensuring transportation for patients, and maintaining effective communication among all healthcare professionals involved in the patient's care.

Key Responsibilities:
  • Conduct thorough assessments of patients' health, encompassing physical, psychological, and social dimensions.
  • Perform medication reviews or reconciliations as needed.
  • Monitor patients' health status and adjust treatment plans accordingly.
  • Collaborate with patients, families, and healthcare professionals to create and update personalized care plans.
  • Ensure care plans encompass chronic disease management, medication oversight, and social determinants of health.
  • Facilitate care coordination among various healthcare providers and social services.
  • Manage a caseload of beneficiaries, coordinating appointments and services as directed.
  • Educate patients and their support systems about chronic conditions and self-management strategies.
  • Document patient-specific needs and maintain accurate medical records.
  • Ensure follow-up care with primary care providers post-hospitalization or emergency visits.
  • Engage beneficiaries and caregivers in self-care management.
  • Facilitate communication between physicians, patients, and caregivers.
  • Identify and refer beneficiaries to suitable community resources and support services.
  • Evaluate the effectiveness of care coordination activities and recommend improvements.
  • Assist in the transition of care, guiding community health workers to support beneficiaries moving from hospital to home or hospice.
  • Provide training on remote monitoring devices and arrange virtual consultations as necessary.
  • Advocate for patients to ensure they receive their entitled Medicare benefits.
Qualifications:
  • Proven experience in care coordination for Medicare beneficiaries within a healthcare setting.
  • Associate Degree and Licensed Practical Nurse certification.
  • Spanish-speaking skills are a plus.
  • Must hold an active Arizona Nursing License.
  • Strong critical thinking and communication abilities.
  • Empathy for elderly patients with chronic conditions.
  • Ability to collaborate effectively with primary care teams and specialists.
  • Current CPR and first aid certification.

This role requires a commitment to maintaining patient confidentiality and compliance with HIPAA regulations.



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