The LVN Care Coordinator manages and coordinates care of moderate risk Accountable Care Organization (ACO) beneficiaries, assists with the development of comprehensive care plans, identifies and closes gaps in care of individual ACO beneficiaries through facilitation of appointments, monitoring referrals, solving transportation issues, tracking investigations, and medication management. In addition, the LVN Care Coordinator participate in patient education regarding preventive and urgent care, palliative care, hospice, medication adherence, and other issues related to chronic disease management. The LVN Care Coordinator ensures delivery of quality, effective, and cost-efficient health care services to ACO beneficiaries by collaborating with primary care providers, specialists, and other members of the care coordination team.
· Identify and coordinate care of moderate risk Medicare Accountable Care beneficiaries through identification and closing of gaps in care.
· Engages with beneficiaries telephonically, at the bedside, and in the clinics.
· Evaluates beneficiaries’ understanding of their conditions and the appropriate behavioral changes necessary to improve such conditions.
· Assists with arranging services such as home health, medical equipment, physician appointments, specialist appointments, and transportation to clinic appointments for ACO beneficiaries.
· Assists the care coordination team in developing and implementing chronic disease care programs to improve quality of care for ACO beneficiaries.
· Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of beneficiaries and their families.
· Functions as liaison between beneficiaries, physicians, hospital administration, and other healthcare providers.
Perform other duties as assigned to meet the organization’s needs.
Required: Minimum of two (2) years nursing experience,Previous Home Health, Hospice, Disease Management, or Case Management experience
Preferred: 3-5 years’ experience in case management or disease management, Certified Case Manager (CCM) or Accredited Case Manager (ACM)
Ability to engage patients over the phone.
Ability to work independently and collaboratively within an interdisciplinary team.
Strong interpersonal communication skills.
Excellent verbal and written communication skills.
Ability to Interact professionally with other healthcare service providers.
Computer literate in electronic documentation system and Microsoft Office products (e.g. Microsoft Word, Microsoft Excel).