Licensed Practical Nurse - Care Coordinator

Job Description

Job Description

Licensed Practical Nurse (Care Coordinator) - Portsmouth, Virginia

Primary Care | Weekdays

Job Description

This Licensed Practical Nurse role focuses on coordinating and delivering Medicare Wellness Visits within a busy family medicine practice. You will manage patient outreach and scheduling, support chronic disease and preventive care, and help patients develop personalized wellness plans. The position combines direct patient care, care coordination, education, and clinical support in an ambulatory primary care setting, with strong emphasis on quality measures, patient engagement, and accurate electronic medical record documentation.

Responsibilities

• Coordinate and provide Medicare Wellness Visits for eligible patients in the primary care practice.
• Use Excel spreadsheets to track patients due for Medicare Wellness Visits, schedule those patients, and record completed visits.
• Collaborate closely with medical assistants and other practice team members to review patient lists, quality measures, and outreach lists, and coordinate care for patients in need of Medicare Wellness Visits or those with identified quality gaps.
• Follow chronic disease management and preventive care guidelines and ensure appropriate plans are developed and completed for each patient.
• Assist patients in developing personalized wellness plans that include realistic goals, action steps, and advanced care planning when appropriate.
• Provide patient education and support to help individuals make informed choices that promote optimal well-being and a higher quality of life.
• Encourage and promote patient engagement and adherence to appointments, treatment recommendations, and other recommended services.
• Complete all tracking and reporting requirements related to patient outcomes and program evaluation.
• Perform phone triage, schedule patient appointments, and call pharmacies as needed.
• Authorize prescription refills within scope of practice and respond to clinical tasks and patient messages in a timely manner.
• Print medication lists, call select patients to review medications, and reconcile medication lists as part of visit preparation and follow-up.
• Respond appropriately to life-threatening situations based on nursing standards, policies, procedures, and established protocols.
• Prepare exam rooms for patient visits, including restocking supplies, sterilizing instruments, and maintaining medical equipment.
• Maintain working knowledge of office procedures such as ECGs, in-house laboratory testing, spirometry, nebulizer treatments, IV insertion and monitoring, Holter monitor application, and assistance with minor surgical and gynecologic procedures.
• Document all nursing interventions accurately and completely in the electronic medical record, ensuring charts are reviewed for completeness, test results, and billing information.
• Review upcoming appointments and scan for additional medical record information needed for visits.
• Complete all assigned tasks for the nursing team, and provide coverage for absent colleagues, including responding to patient messages, prescription refills, lab results, referrals, home health agency communications, medication prior authorizations, patient forms, and physician follow-up.
• Ensure all tasks are reviewed, addressed, and appropriately closed before the end of each business day.
• Respond to questions from patients, family members, clinicians, and other health care providers in a timely and professional manner.
• Answer patient phone calls on the same day they are logged and document all patient conversations in the electronic medical record, noting attempts when patients are not reached.
• Complete required annual recertifications, including OSHA, compliance, respiratory fit testing, IT policy training, and other mandatory education.
• Maintain current CPR/BLS certification and active nursing license.
• Develop and provide a care plan from each Medicare Wellness Visit that includes an updated medication list, individualized patient goals, review of chronic diseases, and health screenings due.
• Schedule preventive and screening tests recommended during the visit.
• Provide diabetes education, including reviewing diabetic flow sheets, teaching self-glucose monitoring, and instructing patients on insulin administration.
• Coordinate transitions of care from the hospital to long-term care and other settings as needed.
• Communicate effectively with continuity providers to support ongoing care and follow-up.

Essential Skills

• Active Licensed Practical Nurse (LPN) license in the state of Virginia.
• Minimum of two years of LPN experience preferred in an ambulatory, family medicine, or similar health care setting.
• Completion of Basic Life Support (BLS) class with recertification every two years.
• Strong clinical judgment and critical thinking skills to support complex patient assessment and management.
• Ability to develop care plans for Medicare Wellness Visits, including chronic disease review and preventive care planning.
• Basic knowledge of educational and behavioral approaches to support patient behavior change.
• Experience with care management, case management, or care coordination in ambulatory or managed care environments.
• Proficiency with electronic health records, preferably Epic, for documentation and task management.
• Competence in phone triage, patient scheduling, and coordination with pharmacies.

Additional Skills & Qualifications

• Experience working in a family medicine or primary care department with exposure to a wide variety of illnesses and treatments.
• Familiarity with quality measures, outreach lists, and population health approaches in primary care.
• Comfort using Excel spreadsheets to track patients, visits, and outcomes.
• Experience with ECGs, in-house labs, spirometry, nebulizer treatments, IV insertion and monitoring, Holter monitor application, and assisting with minor surgical and gynecologic procedures.
• Experience in diabetes education, including reviewing diabetic flow sheets and teaching self-monitoring of blood glucose and insulin administration.
• Experience coordinating transitions of care between hospitals, long-term care facilities, and outpatient providers.
• Ability to participate in and contribute to care management and primary care collaborative meetings.
• Interest in ongoing professional development through educational sessions and modules.
• Strong time-management skills and attention to detail in documentation, record retrieval, and task completion.

Work Environment

• This role is based in a family medicine practice in Portsmouth, Virginia, within a primary care setting. The standard schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. You will work closely with physicians, residents, medical assistants, and other health care professionals in a collaborative, learning-focused environment where employees are encouraged to grow and sharpen their clinical skills. The practice uses an electronic medical record system, including Epic, and standard office and clinical equipment such as ECG machines, in-house laboratory devices, spirometry equipment, nebulizers, IV supplies, Holter monitors, and sterilization tools.

This is a Contract to Hire position based out of Portsmouth, VA.

The pay range for this position is $22.00 - $27.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

This is a fully onsite position in Portsmouth,VA.

This position is anticipated to close on Jun 12, 2026.

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If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email View email address on ziprecruiter.com for other accommodation options.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.