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Community Health Centers of Greater Dayton (CHCGD) is a non-profit health care organization created from a collaborative effort between hospital systems and the local health department. CHCGD promotes a family atmosphere and seeks individuals who have a passion for providing quality patient care and customer service. We offer a competitive salary with very good benefits. Our mission is to improve the health of the underserved communities in Dayton and the surrounding area by providing preventive and primary health care services to patients, regardless of ability to pay.
CHCGD prohibits employment opportunity discrimination against a qualified individual on the basis of race, color, gender, age, religion, national origin, or disability. Employment opportunities include, but are not limited to, employee selection, promotion, training, development, compensation, termination, and corrective action.
LPN Care Coordinator
Department:
Quality and Patient Services
Location:
Dayton, OH
Summary of Position
The LPN Care Coordinator functions, in collaboration and ongoing partnership with chronically ill or �high risk� patients, including Mental Health patients with care management needs, and their family/caregiver(s), Primary Care Provider, and other staff, Specialty providers, as well as other community resources in a team approach to:
� Promote timely access to appropriate care
� Increase utilization of preventive care
� Create and promote adherence to a care plan, developed in coordination with the patient, staff, primary care provider and family/caregiver(s) through Care ManagementCreate and update with patients, a Personalized Prevention Plan during RN-led Annual Wellness Visits
� Reduce emergency room utilization and hospital readmissions with patients identified as high resource use in these areas
� Enhances cost effectiveness by addressing care gaps and avoiding service duplication
� Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care and referrals
� Increase patient�s ability for self-management and shared decision-making
� Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs
� Increase comprehension through culturally and linguistically appropriate education
Principal Duties and Responsibilities
� Work with patients to plan and monitor care:
a) Assess patient�s unmet health and social needs
b) Develop a care plan, with patient, family/caregiver(s) and providers
c) Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate needed changes and follow up plan(s)
d) Create ongoing process for patients and family/caregiver(s) to determine and request care coordination support they need or desire
e) Evaluate outcomes of care
� Lead Annual Wellness Visits as auxiliary staff, creating and updating the patient�s Personalized Prevention Plan and other AWV documentation in the EHR
� Identify gaps in care and implement methods to close gaps, including those attached to quality/value-based payments and bonuses
� Assist in outreach campaigns related to patient engagement, quality initiatives, transitions of care, referrals, etc.
� Identify high utilizers on transitions of care reporting and perform outreach and patient education, as well as evaluate appropriateness of care plan for patients
� Educate patient and family/caregiver(s) about relevant community resources
� Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan regarding transitions of care and referralsIdentify �high risk� patients for Care Management utilizing available reports and recommendations by staff/providers
� Appropriately, and routinely, document activities in the patient�s EHR and care plan
� Attend Care Coordinator and other training courses, webinars, etc. to remain current on regulations, practices, etc.
� Provide feedback to, and participate in QA PDSA�s and other quality initiatives/projects
� Review and track patient outcomes through data systems, reporting, and dashboards
� Perform other duties as assigned
Required Skills or Abilities
1. Ability to manage and prioritize multiple tasks
2. Working knowledge of EHR, Next Gen preferred
3. Proficient in Excel, Word and PowerPoint and ability to learn other computer programs.
4. Good organizational and self-management skills
5. Excellent verbal and written communications skills
6. Ability to communicate with a diverse range of people, from physicians to the patient population
7. Demonstrates knowledge of, and adherence to patient�s rights, confidentiality and HIPAA guidelines and regulations
8. Knowledge of local community health and social welfare resources preferred
9. Ability to relate well to people from diverse ethnic and cultural backgrounds
10. Demonstrates working knowledge of PCMH processes and guidelines preferred
11. Ability to travel to different site locations as necessary
Required Knowledge, Experience or Licensure/Registration
1. Licensed Practical Nurse with current, unrestricted license in the state of Ohio
2. Previous experience in Community Health Center, Care coordination and/or case management experience preferred.
3. Current CPR certification.
4. Knowledge of NextGen EHR preferred
5. Knowledge of ICD-10 and CPT coding preferred
Physical Requirements:
Must be able to see, sit, stand, bend, stoop, hear and lift up to 20 pounds. Must demonstrate
manual dexterity in order to follow necessary clinical procedures.
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