Continuing Care Coordinator LPN - job 1 of 2

Overview

Continuing Care Coordinator LPN

Full Time

Monday-Friday 8am-5pm

CHI Memorial a member of CommonSpirit is an award-winning not-for-profit faith-based health care organization dedicated to the healing ministry of Jesus Christ. Founded by the Sisters of Charity of Nazareth we offer a comprehensive continuum of care from preventative and primary care to acute hospital services specializing in cancer cardiac neuroscience stroke and orthopedic services. Our commitment to excellence has earned us top prestigious recognition repeatedly from U.S. News and World Report PINC AI™ CMS Healthgrades® Leapfrog and most recently as one of the Best Places to Work in Tennessee. We are proud to serve Southeast Tennessee and Northwest Georgia with the expertise of 4700 employees and nearly 500 affiliated physicians.

Responsibilities

Job Summary

The Licensed Vocational Nurse (LVN)/Licensed Practical Nurse (LPN) is responsible for knowing his/her professional scope of orientation period that includes demonstrating skills and behaviors that meet a fully competent level of performance. The LVN performs patient care management services that support the established plan of care as directed by the other licensed staff within the team (department). This includes assisting in relaying instructions from the physician to a patient or authorized person, and collecting patient data, documenting patient concerns, patient messages, and any instructions or education provided within the care management operational platform.  Providing leadership to support staff.

Essential Key Job Responsibilities

Assessment

Conducts screenings based on criteria, refers patients to healthcare programs, specialists and other multidisciplinary team members such as a diabetes health educator, home visit provider, geriatric clinic, home health, pharmacist, etc.

As per guidelines and or red flag criteria escalates to the RN or SW or supervisor when patient needs or concerns are beyond his/her scope of practice.

Assist patients and or caregivers in achieving compliance and improving adherence to plan of care notifying RN/SW or provider of issues and collaborating with multidisciplinary team members (primary care physician, social workers, pharmacists, home visit providers, etc) based on the patient's established plan of care.

Coach's patients, family and/or caregivers about the disease process including how to recognize signs and symptoms of worsening disease and next steps.   Based on care plan or program criteria, identifies appropriate cases to discontinue from the program and collaborates with SW and RN to document rationale accordingly.

Leadership

Performs job with minimal supervision demonstrating ability to make independent self directed decisions in accordance with established policies and procedures, within scope of practice while maintaining a professional attitude. 

Serves as an advocate and liaison between patient/family and physician, hospital staff, members of the health care team, clinic care coordinators, and community resources

Participates in departmental and organizational committees, meetings and projects as applicable.

Critical Thinking

Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments

Assists patients with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures, escalating patients as per scope of practice

Relationships

Develops effective give and take relationships with others including various healthcare team members across the continuum; understands the agendas and perspectives of others; recognizes and effectively balances the interests and needs of one’s own group with those of the broader organization.  Proactively seeks additional clinical input to ensure appropriate level of care/services provided.

Additional Responsibilities

May also be required to meet patients and or family members either in the community, at home, or other location.  Must be able to assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker and/or Registered Nurse member of the care team for further action.

May also be required to:

Concerns or complaints 

Research and recommend appropriate follow-up and or corrective measures

Identify opportunities to achieve department process excellence through a thorough analysis of available data and involvement of interdisciplinary teams

Department Audits

Assist with audits at the direction of the manager

Consolidate audit results and provide analysis of results

Day to day operations:

At the direction of the manager, assist with hiring by organizing peer interviews

Work in conjunction with management to ensure daily performance of staff supports effective, safe and efficient patient care and department operations

Mentor new employees meeting weekly with the employee and or leadership to track progress, ensure appropriate communication with team members

Identifies and actively participates (or leads) projects to assist with team self-actualization

Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project, provides ongoing support to team members in collecting, interpreting, and communication of data, and developing action plans accordingly

Team conferences attend and participate at interdisciplinary team meetings

Initiate patient care conferences when needed

Committee participation outside of operational departmental work

Qualifications

• Graduate of an accredited school of nursing: Licensed Vocational/Practical Nursing
• 2 years relevant experience or advanced degree required
• 3 to 5 years experience preferred
• State issued license as a LPN as outlined below
• Manages and works closely with interdisciplinary partners in the management of identified patient populations. Works with a mix of clinical, operational, and business activities related to that partnership
• Escalates patient care issues based on red flag criteria or other patient care situations beyond scope of practice as identified by the local state regulations
• Implements specific program goals including high priority case management redesign efforts required to improve performance
• Works closely with and in partnership with Community resource partners, Post Acute Care Providers, Acute Care Coordinators and other clinical staff who are focused on care coordination in order to ensure that patients' care and  transition of care  from acute care to post-acute and ambulatory care are seamless
• Escalates any internal and external customer concerns to the RN, SW or market leader
• Excellent computer skills and ability to learn new systems
• Strong organizational (time management) and  interpersonal skills
• Ability to handle multiple priorities with strong attention to detail
• Ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word
• Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)