Lpn Care Coordinator - Clinical Quality - Full-Time

Job Summary:
The Affordable Care Organization (ACO) Care Coordinator ensures the overall success of the ACO by collaboratively working with patients, physicians, ACO Medical assistant and LCSW, to integrate the key features of the ACO. The LPN will be able to perform annual wellness visits (AWV). The focus of the Care coordinator is to drive AWV competition percentages within primary care, work with Transition of care team members to reduce readmissions and promote warm handoffs, address complex care needs rising risk patients as identified through the ACO analytics team. Daily work in Health Endeavors platform will be required.
Care Coordinators will also engage the patient in an active role in the management of his/her disease or medical condition, and promotes education and self-management skills. Assists in the identification of appropriate providers, facilities, and community resources in an effort to improve or maintain patients social, emotional, functional, and physical health status. The focus of the Care Coordinator is to promote whole person health support with emphasis on establishing routine contact with the primary care provider and facilitate specialist referrals and other care as appropriate per physician orders. Additionally, works to coordinate disease registry activities, performance reporting, and regular meetings with stakeholders regarding success or improvements within the medical home.
This position is involved in a team-based approach to care. Team members are trained to meet the highest level of function for their role as per the State of Tennessee/Georgia guidelines. Is trained and assigned (as per their role and responsibilities) to coordinate care for patients and is trained and assigned to support patients/families/caregivers in self-management, self-efficacy and behavior change. Is trained and assigned (as per their role and responsibilities) to manage the practices' patient population. Participates in the practice's quality improvement process and performance evaluation.
Education:
Required:
Licensed Practical Nurse current license held in state of Tennessee
Preferred:
Experience:
Required:
Three to five years experience in direct patient care environment; must be PC literate with basic knowledge of Windows and Microsoft Office. Exceptional skills of independence, organization, communication, problem-solving, professional interactions, and human relation skills, as well as analytical skills and problem solving ability. Proficient with processes to build team and participate in cross-functional teams. Ability to work within specified timeframe requirements.
Position requires Motivational Interviewing techniques and Adult Learning Styles. Excellent oral and written communication skills with problem solving abilities. Exceptional interpersonal communication skills are required. Experience with data collection, documentation review, and statistical analysis.
Preferred:
2 years' experience in Utilization Management, Case Management or Care/Disease Management. Extensive knowledge HCC scores and Risk Stratification.
Position Requirement(s): License/Certification/Registration
Required:
Licensed Practical Nurse with active license in the state of Tennessee or holds a license of their residence if the state is participating in the Nurse Licensure Compact Law.
Preferred:
Department Position Summary:
The ACO Care Coordinator contributes to Erlanger Health System through support of the philosophy and objectives.
RESPONSIBILITIES:
ACO Care Management
Work with all clinical teams as a resource on care management for all patients identified as Complex chronic, Medium chronic, transition of care and episodic. These patients are identified and risk stratified in our electronic health record system, by CMS roster list, referred by providers and other care managers. The responsibilities include the following:
Actively manage assigned panel of patients identified as ACO members
Attend >90% of required education webinars/teleconferences/meetings and training sessions identified by management staff.
Attend staff meetings/huddles/regular care team meetings and peer review activities. Participates in departmental and organizational committees as applicable.
Promotes collaborative teamwork within the department as well as the Care managers team; able to work with all peers in a team situation.
Documentation of all interactions with patients under the proper Care Management' encounters within EPIC.
Ensure pre-population wellness visit workflow completion prior to visit whenever possible.
Optimizes care coordination with hospital, emergency room, consulting physicians, community resources as necessary.
Follow workflow to ensure smooth transition of care for patients treated in a facility (inpatient or emergency room), by a specialty physician or by another health care provider. .
Manage patient care in the health care continuum to achieve optimum outcomes in a safe and cost-effective manner.
Collaborates with physicians, providers, and practice staff in:
Identifying appropriate patients for rising risk management.
Maximizing cost savings within care teams.
Must be able to identify resources and navigate patients to the appropriate resource outside the care managers scope of practice.
Actively participates in monitoring and working to improve the identified quality metrics of the practice used for reporting to CMS within Health Endeavors.
Extensive knowledge of the required metrics, goals, thresholds and reporting structure.
Will attend the required monthly meetings with practice managers as well as monthly productivity meetings with management.
Must be able to produce, educate and explain all reports associated with ACO as well as providing individual providers lists of patients who do not meet the metrics to them in a timely manner to effect change.
Performs additional tasks requested within the scope of Care Mangers role.