Licensed Nurse Care Coordinator - Population Health Job at CHRISTUS Health (Irving)

Licensed Nurse Care Coordinator - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

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.

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

Fulltime

Licensed Nurse Care Coordinator - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

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 is preferred
Proficiency in keyboarding and EHR systems, primarily Epic

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Identify quality gaps. Participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. 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, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation

Fulltime

Licensed Nurse Care Coordinator - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High school diploma required
Minimum of 3 years of clinical or home health experience 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 is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/LPN in the state of employment and/or compact licensure required

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Identify quality gaps. Participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. 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, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation

Fulltime

Licensed Nurse Care Coordinator - Population Health Admin

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High school diploma required
Minimum of 3 years of clinical or home health experience 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 is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/LPN in the state of employment and/or compact licensure required

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Identify quality gaps. Participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. 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, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation

Fulltime

Licensed Vocational Nurse Care Coordinator - Population Health Admin

Provides care under the direct supervision of the Population Health Director of ...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Vocational/technical school graduate
Basic LVN Nursing skills
Knowledge of lab procedures and diagnostic testing
Ability to write clear documentation and ability to write detailed specifications
Solid organizational skills including attention to detail and multi-tasking skills
Basic computer skills
EMR Experience
3 years clinical experience with at least 2 years in a primary care clinic preferred
LVN/LPN License in the state of TX or where positions is located within the enterprise
BLS Certification if applicable

Job Responsibility

Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team
Works in collaboration with the PCMH Team in the design implementation and evaluation of the PMH model as applicable
Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers
Reviews patient medical record to identify care gaps
Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter
Fosters a Team approach by working collaboratively with the member family PCP and other members of the healthcare team to ensure coordination of services
Assists Nurse Navigators’ in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines
Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing
Facilitates a collaborative approach with care team for identification of and closure of care gaps
Utilizes educational and behavioral change strategies to promote patient collaboration with the care team

Fulltime

Licensed Vocational Nurse Care Coordinator - Population Health

Provides care under the direct supervision of the Population Health Director of ...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

LVN License in state of employment or compact

Job Responsibility

Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team
Works in collaboration with the PCMH Team in the design, implementation and evaluation of the PMH model as applicable
Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers
Reviews patient medical record to identify care gaps
Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter
Fosters a Team approach by working collaboratively with the member, family, PCP and other members of the healthcare team to ensure coordination of services
Assists Nurse Navigators’ in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines
Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing
Facilitates a collaborative approach with care team for identification of and closure of care gaps
Utilizes educational and behavioral change strategies to promote patient collaboration with the care team

Fulltime

Licensed Nurse Care Coordinator Senior - Population Health Admin

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High School Diploma required
Minimum of 3 years of clinical or home health experience required
5 years supporting value-based care programs, accountable care organizations, or HEDIS
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 3 years of experience in a physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/ LPN in the state of employment and/or compact licensure required

Job Responsibility

Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices
Monitor and ensure compliance with all regulatory requirements, organizational policies, standing delegated orders and protocols
Identify quality gaps and risk adjustment gaps
Conducts internal review audits to facilitate feedback for documentation and efficiency of the care coordination team
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments
Monitor value-based care quality performance and pulls reports to identify open care gaps
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols
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, practice managers, and their staff

Fulltime

Licensed Nurse Care Coordinator Senior - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High School Diploma required
Minimum of 3 years of clinical or home health experience required
5 years supporting value-based care programs, accountable care organizations, or HEDIS
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 3 years of experience in a physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/ LPN in the state of employment and/or compact licensure required

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices
Assist with work assignments and development of new work processes as needed
Coordinate and assist with associate onboarding
Create education material for training
Monitor and ensure compliance with all regulatory requirements, organizational policies, standing delegated orders and protocols
Identify quality gaps and risk adjustment gaps
Participate in Quality Improvement Programs as indicated
Attend learning sessions and share information learned with team members
Assist in the development of tools, education, and workflow processes to assist the network in meeting CMS, ACO, documentation, and payor quality initiatives

Fulltime

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