Job Description
Job DescriptionDescription:
JOB TITLE: LPN Care Manager
DEPARTMENT: Admin
REPORTS TO: Clinical Quality Director
STATUS: Exempt
About Primary Health Solutions Our Mission
We meet people where they are and partner with them on their journey towards wellness.
Our Vision
The destination for servant leaders to provide comprehensive and exceptional care.
Our Values
R – Respect
I – Innovation
S – Stewardship
E – Excellence
LPN Care Manager Summary
This position is responsible for managing high risk, chronic condition patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes, under the supervision of the Registered Nurse. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcomes. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the
fragmentation of health care delivery systems. This position is committed to improving health status of the individual as well as the Primary Health Solutions community.
A Day in the Life
- Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria. Prioritizes patients according to intensity, need and required follow up.
- Performs holistic assessments for care-managed population. The assessment includes a systematic and pertinent collection of data about the health status of the patient.
- Assist in formulating and implementing a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available. Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients are action oriented. Identifies barriers and empowers patients/families to achieve maximum levels of wellness and self-management. Involves patient/family in the formation and ongoing evaluation of the plan of care.
- Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, barriers/ issues and goals. Monitors and evaluates the progress of the patient.
- Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates discussions with multidisciplinary team regarding patient progress, new needs or problems, etc. Scans for gaps in care to identify patients needing the additional support of care management.
- Identifies social determinants of health needs and effectively utilizes community resources to meet these needs
- May perform follow up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission using established criteria. Performs medication reconciliation for these care transitions.
- Collaborates with providers, other healthcare team members (including inpatient facilities, the patient’s payer and health system administrators) to facilitate transitions of care across the healthcare continuum and optimize clinical and financial outcomes.
- Maintains database on care managed population. Maintains accurate and timely documentation in the EMR and population health tool.
- Performs all duties and responsibilities in accordance with basic principles and guidelines of professional nursing.
- Participates in regular team meetings and appropriate quality and organizational committees.
- Participates in the orientation of new personnel.
- Abides by the organization’s compliance program and requirements.
- Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.
- Drive improvement of clinical quality measures- in partnership with the rest of the quality department.
- Performs all other duties and tasks as assigned which may include vaccine clinics, home visits or other off site nursing needs.
Core Competencies
- Customer Service: Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.
- Communication: Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.
- Dependability: Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.
- Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.
- Productivity: Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, and handles information flow.
Requirements:
Success Requirements
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education/Experience
LPN license required. Proficiency in medication indications and side effects. Understanding of medical tests and requirements for test as to provide the patients with appropriate information. Minimum of 3 year of professional level medical experience; experience in care coordination/care management preferred.
Language Skills
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
Reasoning Ability
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Computer Skills
To perform this job successfully, an individual should have the ability to gain knowledge of current practice management system, electronic medical record, Microsoft Word, text paging, Internet, and Intranet.
Certificates, Licenses, Registrations
Active Ohio LPN license.
Other Applicable Requirements
Excellent communications skills, both written and verbal. Ability to work effectively with all levels of clinical and administrative staff within the health centers and with community providers. Promotes collaborative teamwork. Demonstrates program development and implementation skills. Ability to represent the organization effectively in a variety of settings and with diverse communities. Ability to work within a person-centered medical home model, work with disease management and participate in patient education. Ability to work collaboratively with people of diverse cultures and
lifestyles. Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional. Ability to work independently with minimal supervision and be self-directed and flexible. Ability to work at a high-volume level of accuracy. Ability to speak Spanish desirable.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is frequently required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to sit and stoop, kneel, crouch, or crawl. The employee must regularly lift and /or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee are occasionally exposed to fumes or airborne particles; toxic or caustic chemicals and risk of radiation. The noise level in the work environment is usually moderate.
Affirmative Action/EEO Statement
It is the policy of Primary Health Solutions to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.
Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.