LPN Care Manager - Pediatrics

COMMUNITY HEATH:

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties.

ABOUT THE ROLE:

The Pediatric Care Manager will adhere to standards of care for children including but not limited to developmentally disabled, medically fragile and foster care populations. Develops a patient centered plan of care through collaboration with the patient (as age appropriate), family, appointed guardian and the multi-disciplinary health care team (pediatricians, specialists, school or facility social workers and home or community-based providers) to maximize the pediatric patients functional capacity and ensure their safety with coordinated care efforts. Supports patients who are moving between health care practitioners, inpatient, and outpatient venues (including visiting nurses) and home settings as their condition and care needs change.

FUNCTIONS OF THE POSITION:

• To provide follow-up care to patients based on the level of complexity as identified by any member of the healthcare team.
• To collaborate with the PCP regarding follow-up care and potential post discharge concerns or barriers that have been identified.
• To provide follow-up phone calls post discharge and/or ED visit and will collaborate with the healthcare team.
• May determine that a patient/ parent requires collaboration either by phone or in person
• To follow-up with all hospital discharge patients that do not keep their appointments and provide additional follow-up based on patient needs.
• To collaborate with Visiting Nurses, School districts, Community Health Team, Social worker, RN, Rutland Mental Health, VT. Department of Child and Family Services; various support groups and any other member of the healthcare team as necessary.
• To assist patients that have been identified as needing complex care with individualized programs on an ongoing basis.
• Will attend school coordinated service planning meetings, Rutland Mental Health team meetings, or VT Department of Children and Families safety plan meetings and appointments with other providers when directed by the PCP or requested by the patient/parent.
• Will call to engage families when there is a lapse in care.
• Assists patients in the transition of care from Pediatric to Adult providers.
• Will reach out to families of care managed patients who struggle to keep specialist appointments and assist with supports as needed.
• Will provide follow-up care to all identified patients based on level of complexity, social determinants of health and the identified stratification tool.
• Will collaborate and coordinate care with any potential post discharge concern or barrier that has been identified.
• Will provide transitional care to risk stratified patients post discharge from either outpatient or inpatient venues.
• Will assure that hospital discharged patients have adequate education and knowledge of their medication list.
• Will determine frequency of telephone encounters based on specific patient need.
• Will identify barriers to care (includes social determinants of health) for care managed patients and will reach out to appropriate recourses based on patient needs.
• May determine at any time that a patient requires a face-to-face visit.
• Will have an identified schedule that they will utilize to follow up with their patients.
• Will follow-up with all identified care managed hospital discharge patients that do not keep their appointments and provide additional follow-up based on patient needs.
• Referrals will be made to the Care Manager whenever a primary nurse or provider identifies a complex or high-risk patient. This will be irrespective of whether the patient has been hospitalized.
• Will review patient lists to identify patients requiring care management services.
• Will develop a panel of patients who need care management services by creating a care plan to improve their health outcomes. (i.e ACO, CM)
• Will complete designated self-chart audits.
• Will comply with required expectations for consistent documentation of care management services provided.

SKILLS REQUIRED FOR SUCCESS:

• Current Vermont LPN license.
• CPR Certification.
• Prior experience working in a nursing position required; prior case management experience in a similar outpatient setting preferred.
• Experience in using a variety of electronic medical record and ability to learn other systems, basic keyboarding skills and email communication.

HOW WE SUPPORT YOU:

• Work Life Balance
• Generous Time Off
• Medical, dental, and vision insurance.
• Health savings account option.
• Robust 403 (b) retirement savings plan, with employer match and 100% vesting schedule.
• Comprehensive Wellness Program.