LVN / LPN - Case Manager

Type of Position Requested: LPN FTE Requested: Full Time Guaranteed Hours (Weekly): 40 Requested Schedule: Monday Friday, 8:00 a.m. 4:30 p.m. RGMG Care Manager location Saturday: No Primary Location: RGMG Care Managers Address: Home base is Riedman Administrative Campus. ******This is a mobile position and will require travel, including potential home visits, hospital visits, and patient office visits. Floating: Yes - Rochester General Hospital, Unity Hospital, patient homes; and provider offices Specialty: Adult/Geriatric Focused Locals Accepted: Y - at a lower rate if < 75 miles Unit Accepts 1st time travelers: Y Years of experience Required: 1 - This is a Home Health/Mobile Case Management position. BLS Required Special Skills/Traits Requested: This role will support the Transitions of Care program, which focuses on reducing 30-day readmission rates. LPNs will work under the direction of the RN Care Manager to assist with implementing the care plan. This is not a hands-on nursing role. Responsibilities include, but are not limited to, appointment scheduling, biometric data monitoring, providing and reinforcing education, attending patient visits as needed, completing home visits, connecting patients with community resources, maintaining frequent patient contact, and completing other tasks as directed by the RN. The LPN will be part of a multidisciplinary care team that includes an RN, Social Worker, Pharmacist, and other professionals. Clear and concise communication and documentation skills are essential, as the LPN will document in the EHR. The ideal candidate must be able to work independently and remain flexible throughout the day. Responsibilities will also include attending care team rounds to provide patient updates and managing a monthly rolling caseload of approximately 25 30 patients. Access to reliable transportation is required, as travel may be necessary during the workday. LPNs will not transport patients. Clinical knowledge or experience with CHF, COPD, and multiple complex comorbidities is preferred. Patient Diagnoses: ransitions of Care Program - decrease admission rates Remote work - but could be required to go to patients home or providers office to observe or educate patients Work with RN to implement POC Remote / hospital setting - screen and see pts, telephonic work f/u appointments - triage barriers education taking meds appropriately align with community services screening calls - scoring documents Triage Care Team Rounds (virtual) - social worker / pharmacy / multi disciplinary team Special Procedures/Unit Details: This is not a "hands-on" nursing role. LPNs will complete multiple tasks, including but not limited to appointment scheduling, biometric data monitoring, providing/reinforcing education, attending visits with patients as needed, completing home visits with the patient, linking patients with community resources, frequent patient contact, and other tasks as directed by the RN. ***Care Coordination community resource knowledge preferred no hands-on care 30 day program - reassess goals = close or transition to long term management program 30-40 rotating patients per month Special Equipment: This is a mobile position and will require travel, including the potential for home visits, hospital visits, and patient office visits. Local office - space at administrative building