Reporting to the Chief Executive Officer and the Director of Medical Affairs the LPN for Chronic Care Management will be responsible for utilizing a nursing process to evaluate patient needs over the telephone and provide guidance and education to patients, adhering to organizational policies, procedures and guidelines. Provides high risk patients with chronic disease management and liaises between the patient, hospital, physicians’ office, home care agency, etc. This position is telephonic care coordination as directed by the patient’s physician.
Employees must perform their jobs with a focus on risk management, occupational safety and health, and providing internal and external customer service.
KEY JOB DUTIES AND RESPONSIBILITIES
- Systematic assessment of the patient’s medical, functional, and psycho-social needs and cooperatively develop an integrated patient centered care plan and goals with the client/family and other providers;
- Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education;
- System-based approaches to ensure timely receipt of all recommended preventive care services;
- Medication reconciliation with review of adherence and potential interactions;
- Oversight of patient self-management of medications;
- Coordinating care with home- and community-based clinical service provider;
- Work collaboratively with team members to provide outreach and engagement;
- Manage transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after an emergency department visit, or facility discharge;
- Ensure the electronic care plan is available and shared timely within and outside the billing practice to individuals involved in the patient’s care;
- Collaborate with physicians and other providers to create a Plan of Care for each patient;
- Document medical treatments rendered in the Electronic Medical Record;
- Counsel patients and family members before, during and after treatment;
- Assist the provider during an emergency situation, at the direction of the provider.
REQUIRED KNOWLEDGE, SKILLS, AND COMPETENCIES
- Participate in in-house staff teaching conferences.
- Member of Quality Assurance committee.
- Provides medical case management.
- Performs other related duties as assigned.
- Experience in clinical telephone triage and working with Electronic Health Record (EHR)
This position does not supervise others
- Completion of an accredited LPN program. Licensed by the New York State Department of Education.
- Three years of working experience
- Bi-lingual (English/Spanish) ability is a plus but not required.
The Licensed Practical Nurse is assigned to the Health Center. Maybe required to travel to other sites based on the needs of the agency