LPN Care Manager

LPN Care Manager

Patient Medical

A Brief Overview

As a part of the Patient Medical Team, responsible for identifying high emergency room department users and non-emergent users and coordination of follow up with care with primary care provider. Audits records and collaborate with care team to identify missed opportunities in gap closure, care coordination and care management. Coordinate and facilitate practice level performance improvement initiatives. Assist as needed with responsible for assisting the Care Team with the tracking and coordination of timely, high quality and efficient health care and support services as identified through a multi-disciplinary care plan, self-management goals and referrals to both internal and external resources. Provides administrative support by performing health care promotional events for gap closure and assisting with data collection, aggregation, analysis, and improvement activities.

What you will do

• Coordinates outreach to patients to aid in decreasing emergency room utilization for non-emergent care. Ensures patient follow up in the primary care setting. Assists in collaborating with team for gap closure.
• Coordinates with care team and leadership to facilitate practice level improvement initiatives in the ambulatory setting. Utilizes the (PDSA) Plan Do Study Act cycle to improve gaps in care identified in the practice and collaborates with managed care organizations.
• Works collaboratively with providers, managed care / insurance representatives, patients, information technology, and others in a customer responsive / professional manner, in compliance with Premier Expectations and promoting patient / customer satisfaction to coordinate and implement activities.
• Adheres to and communicates policies, procedures and standards of practices to promote gap closure and health promotions.
• Communicates and understands elements of documentation to ensure gap closure and regulatory compliance in the electronic health record.
• Facilitates and assist in collaborating and ensure practice level (PFAC) Patient Family Advisory Council meetings. Provides follow up at the meetings to patients and care team. Presents / facilitates relevant topics for discussion.
• Coordinates follow-up with patients as prescribed after an emergency department (ED) visit or hospital discharge with primary care provider.
• Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals.
• Collaborate with other members of the Care Coordination and Management team for activities including assistance with implementation of Care Plan.
• Reinforce patient educational needs as identified.
• Manage referrals, when needed, to appropriate agencies required to assist the client in achieving the goals and objectives identified in their Care Plan.
• Assist with patient educational needs and team huddles to facilitate gap closure.
• Identify and utilize cultural and community resources.
• Establish and maintain relationships with identified service providers.
• Assist with data collection and generation of patient registry reports.
• Demonstrate excellence in both internal and external customer service.
• Attends staff meetings, all mandatory in-service and additional continuing education as required. Maintains licensure and certifications.
• Supports and is involved in the organization’s Performance Improvement initiatives.
• Ensure and / or remain in compliance with local, state, and federal regulation.

Qualifications

Physical Demands

Regional One Health is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

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