LPN Outpatient Care Coordinator - Summit Medical Group

Summit Medical Group is seeking an LPN Outpatient Care Coordinator. This is a full time opportunity. This position reports to the Outpatient Transition Manager in collaboration with the Value Based Care Team as part of a multidisciplinary healthcare approach focused on Patient Centered Medical Home initiatives. The LPN Outpatient Care Coordinator provides transition of care services that are designed to ensure health care continuity for Summit Medical Group (SMG) patients. This positions is responsible for managing the postacute care of patients that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions.

Examples of Duties (List does not include all duties assigned)

• Provide transition of care services post inpatient hospitalization or emergency room visit.
• Initiate and maintain communication with multi-disciplinary healthcare team to develop, implement, and evaluate a transition plan of care for SMG patients.
• Assess complexity of care needs and potential/actual issues.
• Arrange post-discharge referrals to Care Management RN, SW and/ to assist with chronic disease management or community resource need.
• Assist with meeting quality metrics.
• Assist patient in scheduling hospital follow up, emergency room follow up and other medical appointments.
• Educate patients on appropriate use of the emergency room, primary care, specialist, and urgent care.
• Facilitate patient understanding of the physician’s treatment plan, including but not limited to medication adherence, preventive care, and self-management skills.
• Facilitate the sharing of medical information across the continuum of care.
• Document transition of care encounters and other clinical correspondence in electronic medical record (EMR).
• Act as an advocate for an individual's health care needs by identifying and communicating potential needs to the patient’s provider.
• Collaborate with skilled nursing facilities to identify inpatient or discharge status as well as confirm SMG patient status.
• Collaborate with home health agencies to ensure ongoing care, support, and education.
• Maintain security and privacy of patients by keeping patient care information confidential.
• Participate in required training and attend team, departmental, and organizational meetings.
• Monitor and improve quality of services provided to patients/caregivers through ongoing participation in team and departmental quality improvement activities.
• Update job knowledge by participating in educational opportunities that support the advancement of Care Coordination including care transitions.
• Participate in the orientation and training of new staff as needed.
• LPN Outpatient Care Coordinator job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities that are required of the employee for this position. To deliver exceptional customer experience and consistently meet the needs of SMG, additional duties responsibilities may change at any time.
• Maintains strictest confidentiality both internally and externally.
• Adheres to expectations of the established corporate compliance plan.
• Actively participates in site-level Quality Improvement Activities. Each employee will contribute to the continual evaluation site performance as well as the implementation and measurement of improvement activities that increase the quality of care provided to patients.
• Performs related work as assigned.

Education

High School Diploma Required
LPN Certification

Experience

Minimum 1 year of clinical experience.

Certification/License

• Valid State of Tennessee Licensed Practical Nurse License.
• Valid Driver's License.