AMBULATORY CARE MANAGER LPN - POPULATION HEALTH
Status: PRN - As Needed
Shift: M-F; 0730-1600
The LPN Care Manager will use clinical and organization knowledge to perform on-going assessment, problem identification, education and follow up with patients and families, as well as resource identification. The LPN Care Manager will work collaboratively with various teams and resources to coordinate care for patients who are at high risk for readmission and/or have complex needs associated with managing chronic conditions.
Experience, Knowledge and Skills:
1. Previous Experience Preferred:
A minimum of 1 year relevant clinical care experience required (ambulatory clinic setting, clinical patient care experience, acute care setting). Previous experience[TP1][SC2] in a clinical supervisory position preferred. Excellent written and oral skills. MS Office computer application experience. Experience using electronic medical records (preferred). Basic familiarity with healthcare-related federal regulations pertaining to clinical issues.
2. Specialized And/or Technical Education Required/Preferred:
Current LPN licensure. BLS. Knowledge of basic operational aspects and clinical standards of care applicable to ambulatory clinic setting (multiple physician specialties preferred).
3. Manual or Physical Skill Required:
Physical ability to perform all ambulatory clinic setting clinical functions.
4. Physical Effort Required:
Overall strength requirement: Light
Strength – Light Push – Occasionally Pull – Occasionally
Carry – Occasionally Lift – Occasionally Sit – Frequently
Stand – Frequently Walk – Frequently
DESCRIPTION OF DUTIES:
1. Oversees an assigned caseload of patients and acts as primary liaison between the patient and the provider.
2. Contributes to the development of a goal-directed, age-appropriate plan of care through an interdisciplinary team process that is prioritized and based on determined medical diagnosis, patient needs, and expected patient outcomes.
3. Comprehensively assesses patients’ goals of care as well as their biophysical, psychosocial, environmental, economic/financial, and discharge planning needs.
4. Engages patient in setting attainable, realistic goals based off the patient’s current chronic condition(s) and available resources. Collaborates with provider as new resources are explored when the opportunities for the patient are absent or in short supply.
5. As needed, procures services and resources, serving as an advocate for patients and families.
6. Interacts with patients, caregivers, and physicians to explore the most appropriate setting to meet patient needs.
7. Communicates patient needs to appropriate professionals (i.e., Social Worker, clinical pharmacist, diabetes educator, dietician) and follows up to ensure needs are met.
8. Participates in interdisciplinary team meetings.
9. Responsible for following comprehensive care plans as developed in close collaboration with provider.
10. Provides necessary coaching to reduce or eliminate high risk behaviors.
11. Intervenes effectively with patients who are in crisis and immediately notifies appropriate personnel to obtain assistance, always ensuring provider is aware.
12. Reviews hospital discharges daily to identify patients who meet criteria for the transitions of care (TCM) program.
13. Documents all communications with patient, caregivers or other healthcare facilities/personnel in the patient’s electronic medical record.
14. Assures all documentation includes tracking and time stamping to support CCM and TCM billing.
15. Ensures annual wellness visits for designated patient are coordinated and scheduled as indicated by their payor plan.
16. Performs pre-visit planning prior the patient visit to include organization of the patient’s medical record. Activities may include determining gaps in care (as related to HEDIS, MIPS, and etc.) and notifying provider as such; ensuring lab work and procedures previously ordered are completed prior to scheduled visit.
17. Serves as a resource and provides education to physicians, patients, caregivers, and professional staff on levels of care, quality of care issues, and regulatory concerns.
18. Confirms post hospitalization plan and intended goals with patient and caregiver and continually evaluates care management services and client outcomes.
19. Contacts discharged patients within 48 hours to ensure understanding of discharged instructions, medication list reconciliation, and appointment coordination.
20. Assures all post discharge follow ups are scheduled and any transportation concerns are addressed.
21. Schedule appointments for specialist referrals, imaging, transportation and other continuity of care resulting from physician office visit or hospital discharge. Obtains any authorizations necessary.
22. Place appointment reminder calls.
23. Assist with medication reconciliation process as requested, including clarification of medication list from pharmacies, IP facilities, etc.
24. Reviews performance metrics with leadership team to improve performance and enhance patient outcomes.
25. Follows Infection Control policies and procedures at all times.
26. Follows North Oaks Health System’s Compliance Programs and Federal and State regulatory guidelines.
27. Maintains professional affiliations as appropriate and enhances professional growth and development; and
28. Performs all other duties as required or assigned.