About Job

Summary:
The LVN Care Coordinator provides patient-centered care under the supervision of the Population Health Director or Nurse Manager, following physician-approved protocols and best practices. The role focuses on care coordination, communication, and proactive follow-up to improve patient health outcomes, reduce admissions/readmissions, and support chronic disease management.

Key Responsibilities:

Manage a large patient caseload (10,000–15,000) with care gaps in collaboration with the healthcare team.
Work with the PCMH (Patient-Centered Medical Home) Team to implement and evaluate care models.
Coordinate preventive and follow-up care for patients using evidence-based protocols.
Review medical records to identify care gaps and schedule preventive services.
Collaborate with patients, families, PCPs, and healthcare teams to ensure effective care coordination.
Support Nurse Navigators with transition-of-care outreach for recently discharged patients.
Use evidence-based guidelines to educate patients on the importance of recommended services.

Experience & Qualifications They Want:

✅ Minimum 2 years’ experience in a primary care clinic setting.
✅ Active LVN license in Texas or Compact License (with clean record).
✅ Experience in care coordination, chronic disease management, and patient education.
✅ Familiarity with transition of care, preventive services, and gap closure.
✅ Ability to manage high patient caseloads in a collaborative healthcare environment.
✅ Strong communication and teamwork skills to work across patients, families, and providers.
✅ Knowledge of evidence-based clinical guidelines and documentation protocols.