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An LVN/ LPN plays a crucial role in managing patient care and ensuring continuity of services. The Care Coordinator is responsible for making telephonic outreaches to members attributed to our value-based contacts. They support the ACO and CIN network providers and practices in successfully meeting quality improvement initiatives, monitoring standards of care and managing high risk multi morbidity patient populations across CHRISTUS Health ministries. The role focuses on improving quality care gaps, promoting preventive care, and improving patient outcomes.
Job Responsibility:
Identify quality gaps and participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments
Conduct telephonic outreach on behalf of providers to close care gaps & address medication adherence
Provide counseling and health education to patients and families
Serve as a subject matter expert in care transitions & quality metrics
Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members
Develop professional working relationships with ACO and CIN network providers
Document relevant, comprehensive information and data using standard assessment tools
Maintain patient chart compliance through proper documentation
Unburden primary care providers by placing approved orders for labs and other screenings
Perform Transition of Care calls on patients transitioning from an inpatient stay to home or emergency department encounter
Must have exceptional oral communication skills, strong organizational skills, and ability to adapt to change
Perform other duties as assigned
Requirements:
High school diploma required
Minimum of 3 years of clinical or home health experience required
LVN/LPN in the state of employment and/or compact licensure required
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and one year of experience in physician practice preferred
Proficiency in keyboarding and EHR systems, primarily Epic.
Nice to have:
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives
Knowledge of physician office practice operations and one year of experience in physician practice