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

Job Description

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

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
Document relevant, comprehensive information and data using standard assessment tools
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
Prepare and maintain Transitions of Care and Care Management reports and provide periodic updates to network leaders
Perform other duties as assigned

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

Nice to have

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

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Licensed Nurse Care Coordinator Senior - Population Health Admin

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