Clinical Care Coordinator, LVN

Clinical Care CoordinatorResponsible for engaging recently hospitalized patients to ensure appropriate follow up medical care and services are provided. The Clinical Care Coordinator (CCC) also evaluates the patient for referral to care management, coaching or other resources to assist in supporting the patients self-management plan. The CCC collaborates with Physicians, Clinic Medical Assistants and Care Managers to ensure patient's needs are addressed timely as identified in policy and through general business operations.Includes but not limited to the following:Responsible for transitional care management servicesCollaborate with the physicians to prevent unnecessary hospital re-admissionsCCC regularly exercises discretion and independent judgement in carrying out job duties and assessing patient needPartner with Care Managers in the ongoing improvement, implementation, and evaluation of the Care Management modelGain proficiency Salinas Valley Health Clinics' electronic medical record system and practice management billing systemAdhere to administrative and assigned practice standards regarding confidentiality.Maintain required documentation for all care management activities.Provides follow-up contact with patient as indicated to ensure compliance with provider's recommendations and treatment plan – medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.Manage designated aspects of the patient's care: referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling servicesResponsible for being available to provide telephone advice per protocol, handle urgent calls and emergent calls, appropriately referring to or involving physicians/case managers when appropriate;Participates in facilitating patient transitions in the care continuum. Serves as the bridge between consulting physicians, hospitals, ER and other frequently used healthcare resources and the patient and/or familyAnticipates the needs of the patient, helping ensure the necessary documentation and referral authorizations are completedCollaborates with the patient, physician, and other care team members in assessing the patient's progress toward individual health care goalsAssesses barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointmentsMaintains accurate and timely documentation of patient contact, and any mutually agreed upon care plans in the patient's medical recordParticipates in measuring clinical outcomes, analysis activities, and quality improvementParticipates in any "integrated population management" initiatives to improve the health status of a particular patient population (e.g., diabetics, asthmatics, smokers, COPD, CHF, etc.)Other duties as assigned.LVN licensed in California.High School diploma or equivalent.American Heart Association BLS.Experience as an LVN in Care Management or in a Medicare and Medi-Cal environment (Home health, Skilled Nursing, Physician Office, Clinic, Hospital). Experience with electronic medical record documentation.Bilingual English/Spanish.Knowledge of Monterey County community resources.Competent in the concept of an Advanced Medical Home.This job has no supervisory responsibilities.Proof of identity and legal authority to work in the U.S. is a condition of employment. Cypress Healthcare Partners/Salinas Valley Health Clinics will not sponsor applicants for work visas.