Licensed Practical Nurse

2 weeks ago

Toledo, Ohio, United States Toledo Clinic Full time

Overview:


The Clinical Care Coordinator plays a pivotal role in ensuring seamless coordination and continuity of care as patients transition between acute care settings and post-acute environments. This position is essential in providing education and discharge planning to maintain care continuity throughout these transitions.

In this role, you will engage with patients and their caregivers to conduct barrier assessments, propose solutions to enhance patient care, advocate for life goals, and contribute to the treatment planning process.

The Clinical Care Coordinator is responsible for ensuring that a patient's treatment plan and overall status are communicated effectively to all providers and caregivers throughout the continuum of care. This role also involves assisting patients in understanding and accessing appropriate care resources, which may be facilitated through phone, email, or in-person interactions.



Key Responsibilities:

Essential Duties Include:

  • Conducting daily post-discharge follow-up calls to meet billing requirements.
  • Performing weekly care outreach to high-risk patients as directed.
  • Documenting all interactions accurately in a computerized database.
  • Proactively anticipating customer needs and providing assistance accordingly.
  • Effectively utilizing computerized telephone systems.
  • Maintaining and processing records, data, and reports related to patient interactions.
  • Assisting with research to identify solutions for customer-related issues.
  • Ensuring customer satisfaction and appropriately documenting all calls, with necessary follow-ups.
  • Initiating problem-solving efforts and striving for continuous improvement in patient satisfaction.
  • De-escalating situations with distressed callers by fostering a collaborative relationship.
  • Upholding the highest standards of confidentiality.
  • Demonstrating the ability to multitask while communicating clearly and professionally.
  • Serving as a resource for education regarding hospice and home care for patients, providers, and caregivers.
  • Educating patients and caregivers on the significance of continuity of care to enhance communication among providers and identify care gaps.

This will ultimately lead to reduced hospital readmissions, improved patient outcomes, and increased satisfaction.



  • Being accessible via phone and email to partners, providers, peers, and supervisors during working hours, with flexibility to accommodate patient and caregiver needs.
  • Traveling to patient locations, such as hospitals and skilled nursing facilities, when necessary to assess patient needs and status.
  • Monitoring the delivery of appropriate home care, hospice, and ancillary services as directed by the care team.
  • Contacting high-risk patients post-discharge to mitigate the risk of rehospitalization.
  • Performing additional duties as assigned.


The above responsibilities are intended to outline the general nature and level of work performed by individuals in this classification. It is not an exhaustive list of all duties performed by those in this role, nor is it intended to limit the authority of any supervisor to assign, direct, and manage the work of employees under their supervision.


Required Knowledge, Skills & Abilities:

Minimum Qualifications:

  • Active LPN licensure in Ohio and Michigan with a minimum of three years of relevant nursing experience.
  • Experience working with diverse populations.
  • Exceptional problem-solving, critical-thinking, organizational, interpersonal, and communication skills.
  • Ability to work independently with attention to detail and follow-through.
  • Capability to function effectively in a critical care environment.
  • Strong prioritization skills and ability to respond to inquiries effectively.
  • Proficient in computer applications (email, Word, Excel, PowerPoint, etc.).
  • Ability to collaborate effectively across various departments and administrative levels.
  • Commitment to comply with all organizational and departmental policies and procedures.
  • Consistent punctuality and professionalism in attire and task completion.
  • Proactive in seeking additional tasks when primary responsibilities are completed and assisting colleagues as needed.
  • Adaptability to expanded roles and responsibilities.
  • Adherence to all clinic policies and procedures.

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