Overview

In this role, you will serve as a pivotal point of contact for patients with chronic conditions, coordinating their care, collaborating with healthcare providers, and ensuring the delivery of high-quality, patient-centered services. This is an on-site office-based position in our Framingham, MA office. Hybrid will be considered.

Responsibilities

• Conduct comprehensive reviews of patients' health status, including chronic conditions, functional abilities, and psychosocial needs based of information from past medical histories.
• Coordinate care plans for patients with chronic conditions, ensuring continuity of care and effective communication between healthcare providers, patients, and other stakeholders.
• Facilitate interdisciplinary team meetings to review patients' progress, discuss care plans, and address any barriers or challenges to care delivery.
• Act as the primary point of contact for the patient or family members to discuss the care plan and answer questions.
• Review patients' medication regimens, identify potential interactions or adherence issues, and collaborate with healthcare providers to optimize medication management.
• Monitor patients' health status, disease progression, and response to treatment through regular assessments, remote monitoring, and follow-up appointments.
• Proactively identify and address any changes or concerns in patients' health status, collaborating with healthcare providers to adjust care plans as needed.
• Provide patient education on chronic disease management, medication adherence, lifestyle modifications, and self-care techniques.
• Facilitate referrals to specialists, diagnostic tests, and community resources as needed, and follow up on patient referrals and orders.
• Maintain accurate and up-to-date documentation of patient assessments, interventions, and outcomes in accordance with regulatory requirements and organizational policies.
• Prepare reports, summaries, and quality improvement data for review by healthcare leadership and regulatory agencies as required.

Qualifications

• Strong clinical assessment and critical thinking skills, with the ability to prioritize and manage multiple tasks efficiently.
• Excellent communication, interpersonal, and teamwork skills, with a patient-centered approach to care.
• Proficiency in using electronic health records (EHR) systems and other healthcare technology solutions.
• Compassion, empathy, and a commitment to providing culturally competent and patient-centered care.
• Graduation from an accredited practical nursing program and current LPN licensure in the state of practice.
• Minimum of 2-3 years of clinical experience in a healthcare setting, with previous experience in case management or care coordination preferred.
• License in CT is preferred, or willingness to get license in CT. 

Employee must be able to perform the essential functions of this position satisfactorily, with or without a reasonable accommodation. Employer retains the right to change or assign other duties to this position.

Joining our team as a LPN within our Chronic Care Management program offers the opportunity to make a meaningful impact on patients' lives while working in a dynamic healthcare environment. If you are passionate about patient care and possess the required skills, we invite you to apply for this rewarding position.