Job Description:

Summary:

The LPN Patient Care Coordinator/Care Manager plays a key role in supporting high-quality patient care across the continuum. This position is responsible for conducting outreach to patients post-discharge as part of the Transitional Care Management (TCM) process, performing quality gap closure activities, and supporting patients in becoming better at self-management through care management interventions. The LPN collaborates with primary care providers, clinical teams, and community resources to address medical, behavioral, and social needs that may impact patient outcomes.

Key Responsibilities:

Transitional Care Management:

• Conduct timely post-discharge outreach to patients within required timeframes (e.g., 2 business days)

• Assess for worsening symptoms, medication adherence, and follow-up care needs

• Escalate clinical concerns to RN or provider as appropriate

• Document patient interactions according to CMS TCM billing requirements

Quality Outreach:

• Contact patients due or overdue for preventive screenings or chronic care follow-up

• Provide education on the importance of screenings (e.g., mammograms, colonoscopies, diabetic eye exams)

• Assist with scheduling appointments and resolving barriers to care

• Accurately document outreach and follow-up steps in the electronic health record (EHR)

Care Management Support:

• Support patients with chronic conditions or complex needs by reinforcing care plans developed by RN Care Managers or Providers

• Identify and address barriers to care/basic social determinants of health and refer to Community Health Navigators when appropriate

• Monitor patient progress, proactively identify additional touchpoints needed for the patient and report concerns regarding non-adherence or worsening conditions

• Provide condition-specific education under the direction of a Registered Nurse

Expectations:

• Meet productivity and documentation standards for outreach and follow-up

• Attend regular team meetings and participate in performance improvement initiatives

• Protect patient confidentiality and comply with HIPAA regulations

Remain flexible to support varying departmental needs including transitions, quality, or care coordination efforts

Requirements:

Graduate of an accredited LPN program. Minimum of 1-year clinical experience, preferably in a primary care or care coordination setting with experience in transitional care management, care coordination, delivery of chronic disease education, or quality improvement.

Core Competencies:

• Clinical Knowledge: Solid foundation in chronic disease management, medication safety, preventive care guidelines and health promotion

• Communication: Clear, compassionate, and professional communication with patients, families, and care teams

• Critical Thinking: Ability to recognize red flags and escalate care appropriately

• Technology Proficiency: Efficient use of electronic health records and communication platforms

• Patient-Centeredness: Empathy and commitment to addressing patient needs holistically

Licenses and Certifications:
Valid and active LPN licensure in appropriate state

Work Requirements:

Shift: Day
On Call: No
Weekends: No
Travel Required: No Travel

Location:
Ballad Health Corporate