About this role
Work Schedule:
0800 to 16:30 Monday through Friday at Hillsdale Hospital clinics
Benefits
• Insurance: medical, prescription, dental, vision, life, disability
• Paid Time Off: vacation, holidays
• Retirement: 403(b) with match
• Education assistance & continuing education; many courses offered on-site at the hospital
Qualifications:
• Current Michigan licensure as an LPN
• Previous experience in caring for chronic disease patients required
• Prefer experience in clinical or community health, care coordination, case management, home health or behavioral health
• Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers if needed
• Must be proficient in communication and computer technologies (email, cell phone, etc.)
• Previous experience with health IT systems, ERMs and data reports
Responsibilities:
• Provides a coordinated, strategic approach to detect early and manage effectively the chronically and/or mentally fragile patient population.
• Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care.
• Assesses patient and family's unmet health and social needs
• Provides effective communications to improve health literacy for patients/families
• Coaches patients/families towards successful self-management of their chronic disease
• Acts as liaison between PCP and Specialists on patient condition as needed between office visits
• Develops a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan
• Monitors patient adherence to plan of care and progress toward goals in a timely fashion, and facilitates changes as needed
• Creates ongoing processes for patients/families to determine and request the level of care coordination support they desire
• Promotes healthy behaviors in all populations and ensures navigation assistance with community resources
• Assists in outreach to patients made after they have been seen in ED or inpatient stay as necessary.
• Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator)
• Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
• Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
• Enrolls patient in Medicaid and assists with other community resource referrals when applicable.
• Ensures effective tracking of test results, medication management, and adherence to follow-up appointments
• Facilitates and attends meetings between patient, families, care team, payers, and community resources
• Ensures all VBR and MSSP metrics are met.
• Assists with VFC (Vaccines for Children) immunization programming at current Primary Care sites.
• Performs other duties as required or assigned.
Equal Opportunity Employer