LPN Care Coordinator

Job Type Full-time Description POSITION SUMMARY Matrix Organizational structure with direct line to Physician Lead of each team for population management outcomes and an indirect line to Practice Manager for completion of TOC and high-risk patient management per policy and related nursing documentation. REPORTING RELATIONSHIPS This position reports to Nurse Manager. CARE COORDINATOR Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that have experienced any transition from a healthcare facility (i.e. ED, hospital, rehabilitation facility, SNF, etc.) to home including follow-up phone calls and the coordination of follow-up visits with the primary care Provider-Team to include: Obtaining daily list of patients admitted and discharged from the hospital, using My Patient Your Patient Software, and meeting with GHP Case Manager to determine accountability for patient TOC management. If the GHP Case Manager is absent, the LPN CC is responsible for completion of all TOC calls and related patient management and for communicating daily with the GHP Case Manager replacement to review TOC data for GHP and Medicare fee for service patients Call assigned transitional care patients within 48 hours of discharge to collect and document information and data from the patients about symptoms, functional status, safety*, *and support at home, current complaint/s, and medication reconciliation Arrange follow-up visits for transitional care patients with the Primary Care Provider-Team within 2-7 days post discharge based on patient needs (within 2-3 days if symptoms not managed, functional status concerns, safety issues, no support at home, medication non-reconciliation) Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that are medium risk, rising risk or high risk and Rising Risk Registry of Patients to include: Run the high-risk stratification tool on a monthly basis, reviewing the list with the lead panel Provider to identify/verify the list high risk panel patients, and then adding high risk patients to Care Coordinators' high-risk registry (list excludes patients managed by GHP Case Manager) Coordinate care of at least 30 high risk patients and rising risk patients within the assigned panel (excludes patients managed by the GHP Care Manager) Obtain and document information and data from the patients about vital signs, symptoms, functional status, safety and support at home, socioeconomic status*, *current complaint/s, and medication reconciliation Review and document the education plan with patients to include use TWC-specific handouts that address basic disease information, symptom management, functional status concerns, safety issues, and medication information and administration information Assist patients with self-management goal setting to improve healthy behaviors and manage chronic illnesses or conditions Bill the CC charges on a daily basis per procedure Coordinate timely referrals of patients with uncontrolled symptoms or unsafe functional problems to 1) the RN Practice Manager, 2) the PCP, or 3) the Senior VP of Clinical Operations or Medical Director as directed Complete of all stat referrals (same day or next day) Participate in the weekly "Huddle" at MVC and CS Attend monthly ACO meetings Manage at least 10 TOC cases at all times MEDICATION MANAGEMENT Complete IV rehydration to patients as assigned Monitor Home INR and Coumadin Safety Program as assigned Ensure immunizations and medications are in stock Prepare and administer medications and injections as per physician or physician extender in absence of registered nurse PATIENT CARE Coordinate timely referrals of patients with socioeconomic issues that interfere with treatment access, transportation, or patient safety to the social worker Conduct lab draws, laboratory testing, and Point of Care testing and will observe, guide and direct Resident blood draws Initiate and monitor insulin pumps per physician orders Conduct ambulatory Blood Pressure Monitoring applications Conduct reading PPDs Triage all panel patient calls and provide consultation in considerate and respectful manner Monitor the closure of labs, diagnostic tests, referrals, and orders for panel patients Track and address partial labs and engage Residents to assist in Ensure labs are addressed timely Observe, guide and direct Resident blood draws Ensure quarterly resident evaluations by patients, staff and physician preceptors to include several patient evaluations per Resident per month Cover the care coordination of patients for other panels as needed when other Care Coordinators are absent Partner with Wilkes University Pharmacy Program to ensure Residents are engaging with the pharmacist students for enhanced patient medication management Partner with GME Supervisor to ensure that adult and pediatric mock codes are held, using AED Complete all required and requested patient forms as needed Ensure that all information that applies to the patient is documented in the EMR MA SUPERVISION Responsible for monitoring the competency of work completed by the MA at least quarterly to include: Pre-visit calls made to patients to ensure patient preparation and issue management (per procedure) New patient data per questionnaires and screening tools are gathered in a professional and accurate process during visit rooming Patient visit BP, BG, and A1c measurements are completed/documented accurately and that screening tool data collection data is gathered in a professional and accurate manner Verbal interactions with patients, other staff, providers and management is considerate and professional Document the competency of MA actions/interventions observed LEADERSHIP AND QUALITY Work with fellow LPNs and the LPN schedule to ensure coverage with the Resident schedule and fill gaps where necessary Coordinate monthly ordering of the medical supplies and vaccinations Coordinate Resident integration into clinical workflow Responsible for Resident orientation to clinic and ongoing engagement in sick line/medication refills, and work to streamline calls Oversee the panel Quality Assurance Plan, PDSAs, and report distribution and sharing with Provider-Team Train new LPNs hired at the clinic and develop and maintain the orientation plan and manual Train front office staff in management of patient questions and related clinical triage Exercise HIPAA confidentiality and security measures at all times during office hours and outside the office Demonstrate responsibility for self-learning through participation in continuing education activities and conferences Serve as clinical resource for staff, clients and families Requirements QUALIFICATIONS Inter