Licensed Nurse Care Coordinator - Population Health

Summary:

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuity of services. The Care Coordinator is responsible for making telephonic outreaches to members attributed to our value-based contacts. They support the ACO and CIN network providers and practices in successfully meeting quality improvement initiatives, monitoring standards of care and managing high risk multi morbidity patient populations across CHRISTUS Health ministries. The role focuses on improving quality care gaps, promoting preventive care, and improving patient outcomes.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Identify quality gaps. Participate in Quality Improvement Programs as indicated.
• Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings.
• Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps and address medication adherence to facilitate star rating and quality performance.
• Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions and quality metrics. Assist in educating practice staff on quality, payor, and government program requirements
• Communicate resources and services available to patients through the continuum of care.
• Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
• Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations.
• Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders.
• Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation.
• Must have exceptional oral communication skills, strong organizational skills, and ability to adapt to change.
• Perform other duties as assigned.

Job Requirements:

Education/Skills
High school diploma required.

Experience
Minimum of 3 years of clinical or home health experience required.
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred.
Knowledge of physician office practice operations and one year of experience in physician practice is preferred.
Proficiency in keyboarding and EHR systems, primarily Epic.

Licenses, Registrations, or Certifications
LVN/LPN in the state of employment and/or compact licensure required.

In accordance with the CHRISTUS Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time