Licensed Nurse Care Coordinator Senior - Population Health

Description Summary: An LVN/ LPN plays a crucial role in managing patient care and ensuring continuity of services. The Care Coordinator is responsible for making telephonic outreaches to members attributed to our value-based contacts. They support the ACO and CIN network providers and practices in successfully meeting quality improvement initiatives, monitoring standards of care and managing high risk multi morbidity patient populations across CHRISTUS Health ministries. The role focuses on improving quality care gaps, promoting preventive care, and improving patient outcomes. Responsibilities: Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices. Assist with work assignments and development of new work processes as needed. Coordinate and assist with associate onboarding. Create education material for training. Monitor and ensure compliance with all regulatory requirements, organizational policies, standing delegated orders and protocols. Identify quality gaps and risk adjustment gaps. Participate in Quality Improvement Programs as indicated. Attend learning sessions and share information learned with team members. Assist in the development of tools, education, and workflow processes to assist the network in meeting CMS, ACO, documentation, and payor quality initiatives. Conducts internal review audits to facilitate feedback for documentation and efficiency of the care coordination team. Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings. Monitor value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance. Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions & quality metrics. Assist in educating practice staff on quality, payor, and government program requirements. Communicate resources and services available to patients through the continuum of care. Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.E., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness. Conduct in-person and virtual meetings with practice managers, staff, providers and managers to communicate program goals, results, and provide education. Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations. Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders. Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation. Prepare and maintain Transitions of Care and Care Management reports and provide periodic updates to network leaders. Must have strong leadership, exceptional oral communication skills, strong organizational and analytical skills, ability to adapt to change and motivate a team. Must have a strong ability to multi-task and coordinate multiple projects. Perform other duties as assigned. Job Requirements: Education/Skills - High School Diploma required. Experience - Minimum of 3 years of clinical or home health experience required. - 5 years supporting value-based care programs, accountable care organizations, or HEDIS - Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred. - Knowledge of physician office practice operations and 3 years of experience in a physician practice is preferred. - Proficiency in keyboarding and EHR systems, primarily Epic. Licenses, Registrations, or Certifications - LVN/ LPN in the state of employment and/or compact licensure required. In accordance with the CHRISTUS Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame. Work Schedule: 8AM - 5PM Monday-Friday Work Type: Full Time