The Patient Care Coordinator-LPN works collaboratively in the ambulatory setting with providers and all other members health care team including diabetic educators, social workers and payer-specific and specialty specific nurse navigators to ensure the highest quality care for all patients regardless of payer type.
This position is an integral part of the Comprehensive Primary Care Plus (CPC+) program, which serves as a form of an advanced Patient Centered Medical Home.
Duties/Responsibilities
Maintain accurate and risk-stratified patient panels for each provider or care team serving as office extension to the current population health team.
Serve as an in-office coordinator to align the needs of the patient with appropriate member of the care team: physicians, CNPs, nurses, MAs, nutritionists, pharmacy, diabetes educators, social workers, etc.
Identify support systems and community resources for all patients regardless of payer when appropriate.
Create care plans for all high-risk patients regardless of payer type.
Identify and close care gaps by scheduling needed appointments, creating actionable telephone notes, and utilizing standing orders across multiple diagnostic categories.
Review notifications of possible non-adherence and care gaps from pharmacies/insurers and create actionable telephone notes to send to the provider when appropriate.
Identify missed and overdue office visit appointments, including wellness visits, and then coordinate the appropriate scheduling of these appointments.
Meet with the patient in office at the time of provider appointment when appropriate and when requested by provider.
Perform pre-visit planning for appropriate patients and update electronic medical record as needed.
Ensure patients discharged from target hospitals are contacted within two (2) business days from time of discharge per CPC+ guidelines.
Minimum/Required Qualifications
Graduate of an Accredited Program in Practical Nursing
LPN-Licensed Practical Nurse in the state of Ohio
Preferred Qualifications
1-2 year’s experience in a similar capacity/setting
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