Sentara LPN Care Coordinator (3654)

Description

ESSENTIAL JOB FUNCTIONS:

Patient care coordinators are liaisons between patients and the healthcare system. As a patient care coordinator you would ensure that patients receive the care they need and that they understand their medical condition medications and other instructions.

Identifyhigh-risk individuals by working with and whilesupportingSentras insurance planand via CVHS electronic record/practice management information.

Perform regular outreach based on the patients personal preference which could include email (if secure) or phone calls.

AssistsSentarasidentifiedcohortsof patients through the healthcare system by acting as a patient advocate and navigator.

Works closely with the Case Manager Patient Educator and others who assess the patient to coordinatepatientscare andestablisha plan of care.

Supports patient self-management of disease and behavior modification interventions.

Coordinates continuity of patient care with external healthcare organizations and facilities by assuring all patient records aresubmittedto the Primary Care Provider.

Helps to managehigh riskpatient care including patients with co-morbidities orhigh riskfor readmission to a hospital setting including a registry.

Promotes clear communication amongst a care team and treating clinicians by ensuring awarenessregardingpatient care plans.

Participatesona team for data collection health outcomes reporting clinical audits and programmatic evaluation related to the Patient-Centered-Medical Home model.

Customize care plans to meet the individual patients needs prioritizing goals for patients health status; establish timeframes for re-evaluation; identify resources to be utilized including the appropriate level of care; plan for continuity of care including transition of care; identify collaborative approaches to be used including family participation.

Work with the patient theirfamilyand/or caregivers toidentifyself-management support.

Effectively research and resolve prescription processing rejections to ensure patients receive medications within established patient service standards.

Work closely with other pharmacy teammates to ensure all orders are received and processedtimelyand accurately.

Receives calls from patients and answers questionsregardingprescription status reimbursement co-paymentassistance health plan drug coverage and other related questions.

Maintainspatient database information including personal physician prescription insurance agency financialassistanceand related data.

Work in a hybrid capacity with scheduled coverage at the mobile health unit 23 days per week.

Participates in Quality Assessment

Participates in ClinicalCollaboratives

Documents each patientencounters in the electronic health record.

Supports ateam-basedapproach to patient-centered medical care.

Attends work as scheduled.

Managersmaymodifyaddor remove essential job functions as necessary or as changing organizational needs require.

Complete annual competencies for current position basic hands-on nursing skills for patient care.

Attend annual skills day offeredfornursing staff.

Assistwith patient care within the sitein the event ofa catastrophic nursing shortage andwhenall other resources have beenutilized.

Performs other duties as assigned.

KNOWLEDGE SKILLS AND ABILITIES:

Demonstrates competence in performing essential duties.

Ability to plan.

Concern forpatient confidentiality.

Shows initiative and ability to use sound judgement in the absence of specific orders.

Resourceful

Patient Advocate

EDUCATION TRAINING AND EXPERIENCE:

Graduate of accredited school of nursing with Licensed by the Virginia State Board of Nursing or from a compact state*.

Data entryretrievaland report generation experience.

Required: 3 years in office clinical experience

Required Experience:

IC