Licensed Practical Nurse Care Facilitator

2 weeks ago

Dallas City, Illinois, United States The Wright Center Medical Group Full time

Job Type: Full-time

POSITION SUMMARY
This role operates within a Matrix Organizational structure, reporting directly to the Physician Lead of each team for population management outcomes, while maintaining an indirect line to the Practice Manager for the completion of Transition of Care (TOC) and high-risk patient management in accordance with established policies and nursing documentation.

REPORTING RELATIONSHIPS
The position reports to the Nurse Manager and collaborates closely with clinical staff, residents, physicians, providers, and practice managers.

LICENSED PRACTICAL NURSE CARE FACILITATOR
In alignment with our Core Values, the Licensed Practical Nurse Care Facilitator will:

  • Oversee the care coordination for a designated panel of patients, including those not covered by Geisinger or Medicare fee-for-service, who have transitioned from healthcare facilities (e.g., Emergency Department, hospital, rehabilitation center, Skilled Nursing Facility) back to their homes. This includes follow-up communications and the organization of subsequent visits with the Primary Care Provider-Team.

Key responsibilities include:

  • Obtaining daily lists of patients admitted and discharged from hospitals, utilizing relevant software, and collaborating with Case Managers to ensure accountability for patient TOC management.
  • Conducting follow-up calls with transitional care patients within 48 hours of discharge to gather and document information regarding symptoms, functional status, safety, support at home, current complaints, and medication reconciliation.
  • Arranging follow-up appointments for transitional care patients with the Primary Care Provider-Team within 2-7 days post-discharge, based on individual patient needs.

CARE COORDINATION
Manage the care coordination for assigned patients categorized as medium, rising, or high risk, including:

  • Monthly utilization of a high-risk stratification tool to review and verify high-risk patients with the lead panel Provider.
  • Coordinating care for at least 30 high-risk and rising-risk patients, ensuring comprehensive documentation of vital signs, symptoms, functional status, and medication reconciliation.
  • Developing and reviewing educational plans with patients, utilizing specific handouts that address disease management, safety concerns, and medication administration.
  • Assisting patients in setting self-management goals to promote healthy behaviors and effectively manage chronic conditions.

MEDICATION MANAGEMENT
Responsibilities include:

  • Administering IV rehydration as assigned and monitoring safety programs related to anticoagulation.
  • Ensuring the availability of immunizations and medications, preparing and administering medications as directed by physicians.

PATIENT CARE
Facilitate timely referrals for patients facing socioeconomic barriers to treatment, ensuring access to necessary resources.

Conduct laboratory draws and Point of Care testing, while supervising and guiding residents in blood draw procedures.

SUPERVISION
Monitor the competency of Medical Assistants on a quarterly basis, ensuring:

  • Accurate pre-visit calls to patients.
  • Professional gathering of new patient data.
  • Precise documentation of patient measurements and screening tool data.

LEADERSHIP & QUALITY
Coordinate the monthly ordering of medical supplies and vaccinations, facilitate resident integration into clinical workflows, and oversee quality assurance plans.

OTHER FUNCTIONS & RESPONSIBILITIES
Perform additional duties as assigned.

REQUIRED QUALIFICATIONS
Licensed Practical Nurse with 3-5 years of experience in a healthcare setting, proficiency in Microsoft Office Suite, and CPR Certification.

PREFERRED QUALIFICATIONS
Experience with electronic medical records is advantageous.

LICENSES/CERTIFICATIONS
Current LPN Certification and certification from the PA LPN State Board of Nursing.

CUSTOMER SERVICE METRICS
Maintain standards for patient communication and documentation to ensure quality care delivery.

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