Nurse Care Coordinator - LVN
The Clinical Care Coordinator is a professional nurse who coordinates care for primary care patients in their home or place of residence. The patient’s care is based on their medical needs under the supervision, medical orders and care of a physician or provider. The Nurse triages patients change in condition and identifies issues that can support the patients care, or escalates urgent issues to the home visit physician or provider. The nurse works directly with the home visit medical director and home visit physician(s). The nurse is responsible for coordinating care of the patients, such as ensuring referrals to other services, and completing appropriate authorization documentation. The nurse provides follow-up by monitoring patients and / or their family’s response to their care. The nurse effectively communicates to patients, families, caregivers and the multidisciplinary clinical teams.
- Prioritizes new patient referrals and completes patient intake by gathering patient information for assessment from the patient, the patient’s family or other health care team members.
- Effectively communicates and responds to patient calls or messages by triaging patient calls regarding their symptoms or medical needs.
- Follow-up to patient requests for medication refills, labs results, tests to be scheduled and coordinates care by communicating directly to the physician to obtain orders as needed.
- Collaborates and coordinates care with case managers, home health nurses, primary care physician, and the patients care team.
- Works directly with physicians about the patients status and medical concerns.
- Proficient use of the EMR system (Epic preferred) to manage scheduling system, to open and close doctors templates.
- Prioritizes urgent patients to be scheduled and adept in scheduling patients by regional locality.
- Monitor and track physician schedule and communicate any changes to their schedule.
- Cross-covers staffing and supports the Post-Discharge Clinic as assigned.
- Initiates DME authorizations and medication prior authorizations.
- Administers vaccines in patient’s home, such as the flu vaccine, Covid vaccines and other medications as ordered.
- Applies previous nursing experience and knowledge and supports the patient’s needs with the patient and family in a home setting.
- Assesses for the presence of advanced directives and facilitates further action in obtaining information about or implementing advanced directives if indicated.
- Anticipates home care needs and utilizes Company programs or community resources to facilitate problem solving.
- Coordinates and evaluates safe, competent care with home visit patients and their families.
- Nurse exhibits excellent communication skills, both written and verbal.
- Maintains an updated medical record on each patient at all times, meeting the required documentation of care coordination.
- Documents patient, family and caregiver communications in the patient’s medical EMR records.
- The Nurse demonstrates professionalism and accountability for patient care coordination in the home visit program
- Nurse delivers excellent patient care service and assists in creating a positive environment.
- Exhibits awareness and respect for the patient and their family home or home-like setting as a care environment.
- Addresses concerns or complaints voiced by patients, families, caregivers, or other internal and external customers, and notifies manager or physician.
- Demonstrates understanding of differences in cultural, spiritual, and socioeconomic backgrounds.
- Involves the patient and family in the plan of care, incorporating their cultural, spiritual, and other belief systems.
- Maintains patient privacy and confidentiality at all times.
- LVN or RN license - Required
- Flexible to travel and visit patients homes - Required
- 2 years’ experience working in an ambulatory health care environment – Preferred
- Experience in Care Coordination working in Case Management or Home Health Nursing
- EMR experience – EPIC - Preferred