Position Summary:

The LPN/Care Coordinator works in collaboration and continuous partnership with patients and their family/caregiver(s), hospitals, specialty providers and staff, and community resources in a team approach. The LPN also provides supportive functions to NHS providers.

Essential Functions & Responsibilities:

General Nursing:

• Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
• Handles incoming triage calls: (LPN under the supervision of RN and Medical Director)
• Provides appropriate patient education regarding medical condition
• Provides medication instructions
• Supports providers by following up with patients regarding their lab/imaging results as guided by the provider
• Documents telephone discussions in the patient’s electronic medical record (EMR)
• Handles incoming Nursing Home Orders
• Handles incoming pharmacy questions, clarifications and prior authorizations
• Calls patients with medication changes, directions and education, as ordered by providers
• Provides nursing support, when needed, to the RNs and NHS providers
• Utilizes the Patient Portal to communicate with patients

Sees patients on daily nurse schedule:

• Responds to the needs of walk-in patients
• Assists providers and clinic RNs as needed
• Provides (RN) or reinforces (LPN) education on medical condition, e.g., asthma, diabetes, family planning
• Reads and documents PPD results
• Provides refill requests that come through the EMR, phone or fax
• Reconciles medications
• Maintains an emergency box of medications
• Oversees the application/enrollment and tracking process for patients in indigent medication programs
• Prescribes medications per standing order protocols, e.g., STI treatment, Vitamin D deficiency (RN only)
• Provides community-based nursing care as established by the organization, as requested

Care Coordination/Case Management Support:

• Maintains Health Care Home (HCH) and FUHN registries for patient follow-up:
• Assists with the identification of “high risk” patients (those with chronic illness and/or special health care needs)
• Contacts patients to enroll them into HCH and documents patient’s acceptance or declination, to populate the registry
• Contacts patients that are on the FUHN ID/ Stratification tool to get them in for follow-up care and educates patients on when to utilize the ER
• Reviews FUHN/ID Stratification patient’s EMR to see what patients may need; refers to specialty providers and to help with medication reconciliation
• Works with patients to plan and monitor care:
• Assesses patient’s unmet health and social needs
• Develops a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
• Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed
• Creates ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire
• Facilitates patient access to appropriate medical and specialty providers
• Educates patient and family/caregiver(s) about relevant community resources
• Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referrals
• Facilitates and attends HCH meetings between patient, family/caregiver(s) and provider
• In collaboration with the primary care provider, assigns the appropriate tiering level based on required criteria for HCH patients
• Advocates for the participant in understanding needs surrounding transportation, shelter, child care and safety. Refers participant to behavioral health services if warranted
• Keeps EMR care plans updated for easy access by HCH Team
• Interacts, communicates and collaborates with HCH Team daily in-person, by phone, inbox messaging and/or team huddles to update and advance care coordination within the Team
• Utilizes all available tools to deliver education, instruction, care coordination and training, including: computer; patient registry; HCH brochure; HCH care plan; other HCH policies & procedures (tiering process, pre-visit planning, screening process); after-visit summaries; disease management brochures; disease management participant tracking records (Diabetes glucose records, nutritional records, wellness/exercise plan, blood pressure record); disease-specific educational handouts; services offered by NHS.

Qualifications:

• Graduation from an accredited nursing program
• Current Minnesota LPN license/certification
• Minimum one year experience in a primary care setting preferred
• Patient education experience
• Family planning experience highly desired
• Motivated to improve the health of the community
• Excellent interpersonal communication

$4k Sign-On Bonus

Benefits:

Neighborhood HealthSource offers competitive pay and benefits among community health centers. Eligible employees (24 hours/week or more) receive benefits including:

• Generous paid time off and holidays
• Health insurance
• Life insurance
• Disability insurance
• Flexible spending account
• Optional 403(b) retirement, vision, and dental plans
• 403 (b) matching- After one year, there is a 3% matching contribution that starts at 20% vesting.
• Federal Loan Repayment Eligibility for Medical/Behavioral Health Providers and RNs
• Mileage reimbursement for travel between clinics and to/from outreach events.

NHS IS AN AA/EOE Employer

Job Type: Full-time

Pay: $26.00 - $32.00 per hour

Work Location: In person