LPN Patient Care Coordinator - TMG Operations (Days)

Works collaboratively with physicians, staff and other health care professionals to provide a medical home and care coordination across the health care continuum for all patients within the physician office setting. Is an integral member of the health care team who works to ensure safety, best practice and high-quality standards of care are maintained across the continuum. Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population. Success will be measured by the results of the process and outcome performance measures of the population of patients in the clinic. Works closely with the MCI Quality Committee Team. Works closely with the PCMH Development Team, the Ambulatory Quality Council, Care Coordinator Manager, and Director of Strategic Initiatives.

Education
High School Diploma plus 1-year vocational school

Experience
One year of related experience. Requires a working knowledge of standard practices and procedures.

Licenses & Certifications

• Georgia Licensed Practical Nurse or Multistate Nursing license

Qualifications

• Must be proficient at computer programs such as Word, Meditech and Epic.
• Must possess excellent verbal and written communication skills

Area of Responsibilities

• Co-ordinates the functions and education/educational materials of the back office staff in the Patient Centered Medical Home as relates to pre-visit chart reviews and data collection including:(a) Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.(b) When standing orders allow it the interventions may be ordered or completed before the patient sees a provider.(c) Fills out pre-visit forms or initiates office visits forms to communicate the review to the provider.
• Coordination of Care across the care continuum including:(a) Assists as liaison with patients and their families to physicians, clinical staff, and other departments.(b) Acting as a liaison with hospitalized patients and the clinic. Following up with patients by phone shortly after hospital discharge.(c) Acting as a liaison with specialty clinics.(d) Proactively acts as patient advocate, responding to and working to resolve patient concerns.(e) Providing a link to community resources.
• Involvement in QI activities:(a) Assesses clinic needs and then collaborates with Clinic Manager on strategies to achieve individual clinic level goals such as quality and efficiency.(b) Actively participates/coordinates committees as needed/requested, i.e. Performance Improvement Teams.(c) Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report findings.(d) Meets on a regular basis with other Tanner Medical Group population health managers, as coordinated by TMG Administration, for information sharing and continuing education activities.
• Oversees and analyzes data for the disease registry database including: (a) Assuring database is kept up to date. (b) Identifying patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate.(c) Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.(d) Creating patient, physician, and clinic level quality performance reports.
• Works with patients and families on Self-Management Support including:(a) Setting short and long-term goals for self-management of chronic disease.(b) Addressing medication adherence in patients not meeting outcome goals.(c) Works with patient to create a plan for Health Behavior Change utilizing the 5A's approach. Assessing and working on the patient's readiness to change, the importance of change, and confidence in ability to change. Helping the patient to identify and overcome barriers.(d) Makes a plan for follow-up between visits.(e) Provides or arranges needed patient education regarding specific health care skills and general disease concepts.(f) Assist with shared medical appointments.(g) Communicating face to face in the office setting, by telephone, or by e-mail.
• Accurately and legibly documents all patient interactions in the patient record.
• Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPPA guidelines and regulations.
• Answers and routes multiple telephone calls and faxes, takes and directs messages and information pertinent to chronic disease management. Receives and arranges appointments for providers and patients for patient meetings, procedures, and appointments and sends correspondence as designated.
• Applies professional nursing skills in the provision of preventive health maintenance and/or treatment of illness.
• Assess learning needs of patient and significant other to support the patient through the care continuum.
• Complies with dress code and strives to act professionally in words and actions at all times.
• Demonstrates a positive attitude by smiling and being courteous to all patients, coworkers and providers, making every effort to be non-judgmental with comments and conversation.
• Demonstrates clinical leadership as evidenced by previous work related activities and performances.
• Demonstrates current level of knowledge of various payor regulations
• Demonstrates effective organizational skills.
• Demonstrates expert practice skills that include flexibility, priority setting, problems-solving, conflict resolution, negotiating and networking skills, decision-making, work delegation and organization, and verbal/written communication skills.
• Demonstrates self-directed learning needs and seeks way to meet own professional development.
• Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations.
• Documents program specific outcomes.
• Facilitates interdisciplinary communication.
• General LPN Duties
• Maintains confidentiality of patient, personnel, and institutional information
• MARGINAL FUNCTIONS: Responsible for following equipment maintenance protocol, identifying problems, and coordinating appropriate repairs.
• Miscellaneous office duties such as greeting patients, answering phone, filling and/or retrieving medical records, and scheduling patient appointments.
• Operates various office machines (i.e. fax, copier, phone and computer).
• Participates effectively as a team member in the clinic being accountable, helpful and welcoming to co-workers, providers and patients.
• Participates in orientation and staff development activities as requested.
• Proactively acts as patient advocate, responding with empathy and respect to resolve patient concerns and recognizes opportunities for improvement through patient concerns.
• Proactively continues to educate self to provide quality care and improve professional skills.
• Types correspondence (memos and letters), statistical forms and procedures and is able to maintain complete patient records while keeping complete patient confidentiality.
• Works independently to assess and evaluate understanding of disease process, treatment plan and/or lifestyle changes.

Compliance Statement
Employee performs within the prescribed limits of Tanner Health System's Ethics and Compliance program. Is responsible to detect, observe, and report compliance variances to their immediate supervisor, the Compliance Officer, or the Hotline.

Education
High School Diploma plus 1-year vocational school

Experience
One year of related experience. Requires a working knowledge of standard practices and procedures.

Licenses & Certifications

• GEORGIA LICENSED PRACTICAL NURSE OR MULTISTATE NURSING LICENSE

Supervision

• The Patient Care Coordinator will serve as a nurse leader and may provide instructions to other members of the clinical staff.

Qualifications

• Must be proficient at computer programs such as Word, Meditech and Epic.
• Must possess excellent verbal and written communication skills

Definitions

• Works collaboratively with physicians, staff and other health care professionals to provide a medical home and care coordination across the health care continuum for all patients within the physician office setting. Is an integral member of the health care team who works to ensure safety, best practice and high-quality standards of care are maintained across the continuum. Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population. Success will be measured by the results of the process and outcome performance measures of the population of patients in the clinic. Works closely with the MCI Quality Committee Team. Works closely with the PCMH Development Team, the Ambulatory Quality Council, Care Coordinator Manager, and Director of Strategic Initiatives.

Contact With Others
Requires frequent contact with many persons at different levels inside and outside of the organization to carry out organization policies and programs and obtain willing acceptance, consent, or action.

Effect Of Error
Probable errors not easily detected and may adversely affect external as well as internal relationships and may result in major expenditures for equipment, materials, or procedures detrimental to the patient's welfare or the organization's interest. Work is subject to general review only and requires considerable accuracy and responsibility. Continually works with reports, records, plans, and programs of a major functional area of the organization where integrity is required to safeguard the organization's position. Duties may involve the preparation of data on which the administration bases important decisions and are highly confidential.

Supervisory Responsibility
Has limited supervision over a small section of employees (up to 15), i.e. assigns and directs their work; instructs new employees and corrects results, may discuss with supervisor, but has no authority over job content or personnel. Team governance where the Members evaluate, interview, and recommend personnel actions.

Mental Demands
Work involves a variety of complex problems to be solved under general organization policies. Ingenuity and judgment are required to review facts, plan work, estimate costs, and deal with factors not easily evaluated, interpret results, draw conclusions, and take or recommend action. Solutions to problems often require coordination with other departments.

Physical Effort
Medium physical effort - Lifts, carries, or handles lightweight (1 to 25 lbs.) materials or equipment for most of the day. Occasional physical effort with medium weight objects (25-60 lbs.). Very occasional physical effort with heavy objects (over 60 lbs.).Works in reaching or strained positions for about half of day.

Working Conditions
Moderate - (About 50% of the day) Involved in exposure to dirt, odors, noise, or some work is performed with exposure to temperature/weather extremes/occupational risk. Limited probability of coming into contact with blood borne pathogens, other potentially infectious diseases, or biomedical/bio-hazardous materials.

Working Conditions Aspects For Immunizations

• Performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps (needles)
• Directly works with Patients less than 12 months of age

Physical Aspects

Continually (at least once per day)

• Visual

Frequently (at least 3 times a week)

• Bending
• Typing
• Manual Dexterity - picking, pinching With fingers etc.
• Feeling (Touch) - determining temperature, texture, by touching
• Hearing
• Reaching - below shoulder
• Color Vision
• Speaking
• Standing
• Walking
• Lifting up To 25 lbs.
• Handling - seizing, holding, grasping
• Pushing/Pulling - up To 25 lbs.
• Pushing/Pulling - 25 To 60 lbs.

Occasionally (at least once a month)

• Reaching - above shoulder
• Balancing
• Crawling
• Running - In response To an emergency
• Lifting 25 To 60 lbs.
• Lifting over 60 lbs.
• Carrying
• Climbing
• Kneeling
• Squatting
• Smelling
• N95 Respirator usage (PPE)
• Hazmat suit usage (PPE)
• Pushing/Pulling - over 60 lbs.