LPN Care Coordinator - Care Transformation

General Summary of Position
Serves as a member of the interdisciplinary care management team capable of furnishing an array of care coordination services to Medicare FFS beneficiaries attributed to practices that the Care Transformation Organization (CTO) supports. Responsible for the care coordination of Medicare beneficiaries attributed to a medical practice(s); Serves as the liaison between the medical practice and the CTOs interdisciplinary care management team.
EDUCATION : Associates degree from National League for Nursing accredited program, or diploma from National League for nursing accredited program.
EXPERIENCE: 3 years work experience including 1 or more years of proven case management project management and population health coordination experience. Experience with data collection and reporting, preferred. Community Outreach experience, preferred. Familiarity with the local area and/or Population Health workforce integration. Experience working in an ambulatory setting preferred.
LICENSE/CERT/REG: Valid Maryland LPN license required.
SKILLS: Effective verbal and written communication skills. Excellent interpersonal and customer service skills especially serving geriatric patients. Strong analytical and critical thinking skills. Strong community engagement and facilitation skills. Advanced project management skills. Commitment to collective impact concepts. Flexibility and the ability to work autonomously as well as take direction as needed. Cultural competency. Proficient computer skills along with experience using Microsoft applications-Word, Excel, etc. and familiarity with entering data in an electronic medical record (EMR)
Primary Duties and Responsibilities

  • In collaboration with the interdisciplinary care team, acts as primary care team agent for the coordination of care for a panel of attributed Medicare beneficiaries by ensuring the following:
  • Attributed beneficiaries have timely access to care (same day or next day access to the patient's own practitioner and/or care team for urgent care or transition management)
  • Facilitates use of alternatives for care outside of the traditional office visit to increase access to the care team and the practitioner, such as e-visits, phone visits, group visits, home visits, and visits in alternate locations (senior centers, assisted living) captured in the medical record
  • Assist patients with scheduling appointments with providers including annual wellness visits. Attributed beneficiaries receive a follow up interaction from the practice within 2 days for hospital discharge and within one week for Emergency Department (ED) discharges.
  • Coordinates referral management for attributed beneficiaries seeking care from high-volume and/or high-cost specialists as well as EDs and hospitals
  • Facilitate connection to services for patients who may benefit from behavioral health services, including: patients with serious mental illness; patients with substance use disorders' patients with depression, anxiety, or other mental health conditions; patients with behavioral and social risk factors and BH issues; patients with multiple co-morbidities and BH issues
  • Assist with identifying patients to participate in the Patient-Family/ Caregiver Advisory Council (PFAC) and help to organize and facilitate the PFAC annual meetings
  • Engage attributed beneficiaries and caregivers in a collaborative process for advance care planning (MOLST, Advanced Directives, Proxy) and directs patients in self management care for high risk conditions and high frequency conditions
  • Builds and maintains relationships with practice staff, interdisciplinary care team and community resource partners.
  • Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.
  • Daily telephonic patient communication to help to close gaps in care and provide up-to-date healthcare information helping to facilitate the members understanding of his/her health status using available reports including quality m page andHIE CRISP to ensure relevant medical history/encounter are accessible in EMR.
  • Facilitates ongoing communication amongst practice and care team by participating in huddles, hosting regular conference calls, in-person meetings, or coordinating regular email updates to ensure alignment of activity, discuss new developments, and exchange information.
  • Perform analysis of attributed beneficiary data and presents data intelligently and creatively in a way that can be easily and quickly grasped by the practice and interdisciplinary care team as appropriate.
  • Participates and supports multidisciplinary quality initiatives to close care gaps and service improvement teams as appropriate. Participates in meetings including: regular staff meetings, All staff meetings, training classes for safety, infection control, OSHA, EMR, CPR, TJC, safety, compliance and others as required; Serves on committees and represents the department and facility in community outreach efforts as appropriate.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.

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