Chronic Care Coordinator/LPN

Company: Southcoast Health
Location: Savannah
Posted on: May 15, 2022

Job Description:

Job Description SouthCoast Health Is Looking For A Full-Time Chronic Care Coordinator The role of the Chronic Care Coordinator is to assist the Care Team (Provider, nurse, medical assistant, other health providers and CCC---s/PCC---s) in optimizing health and quality of life for individuals with multiple chronic conditions by: Following up on the care for panel patients, so as to offer management of care during intervals between face to face interactions with the healthcare delivery system in order to facilitate patients being cared for at the lowest level of care possible Coordination of services for all patients who are part of the assigned panels, which includes patients with: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; Will provide advocacy, information and referral services to patients and families to address their medical and psychosocial needs in accordance with the physician---s written plan of care. Qualifications: Knowledge in appropriate assessment and assistance techniques. Knowledge in health information management by appropriately charting patient data. Knowledge in the utilization of tact. Knowledge and demonstrated proficiency in performing clinical skills. Ability to communicate clearly, with emphasis on excellent telephone skills. Ability to exercise professionalism in dealing with all levels of personnel, patients, and patients families. Responsibilities: Review of the patient care plans, initiation of telephone communication to the panel patients, discussion of the care plan with the patient, and, clarification of expectations related to the care plan. Handle non-appointment related calls from assigned panel patients that involve care coordination, follow-up, etc. Assist patients with community resources as needed. Keep physician informed of patient condition changes and potential changes in the plan of care. Provide an effective communication link between assigned patients/caregivers and medical staff, including relaying messages from providers, gathering information from patients for providers, etc. Support patients and providers in the Chronic Care Program, with care compliance when such intervention requires resources, community referrals, etc Ensure that all panel patients are tracked for follow-up and reporting. Ensure that pertinent data and tracking information is entered into the PM and or EMR systems. Regularly review registry information for assigned panel of patients and arrange for care needed to proactively coordinate healthcare needs. Coordinate with the medical staff to ensure that care management services are provided to patients with complex medical and/or psychosocial problems. Work with the medical staff to develop, implement and carry out programs in chronic disease management for patients, with such problems as diabetes, asthma, congestive heart failure, hypertension, depression, and other disease/condition states based on chronic disease management model. Ensure that disease and other registry data entry is up to date and use registry reports to organize plan of care for complex patients on assigned panel. Education/Experience: Graduate from an accredited practical/ vocational nursing program. Minimum of one year clinical experience, preferably in a hospital or office practice setting working with complex medical needs. Requirement : Unrestricted LPN license Benefits: Competitive salary, health, HSA, dental, vision, life, long term disability, 401(k), supplemental insurance policies. Paid vacation, holidays, sick time, jury duty and bereavement leave. DFW, EOE, MFVD

Keywords: Southcoast Health, Savannah , Chronic Care Coordinator/LPN, Healthcare , Savannah, Georgia