Continuing Care LVN Coordinator

CommonSpirit Health•Bakersfield, CA

4d•Remote

About The Position

As the Continuing Care LVN Coordinator, you will perform patient care management services that support the established plan of care as directed by the other licensed staff within the department. Every day, you will assist in relaying instructions from the physician to a patient or authorized person, as well as collecting patient data, documenting patient concerns, patient messages, and any instructions or education provided within the care management operational platform. The LVN will also provide leadership to support staff. To be successful, you will demonstrate outstanding assessment and communication skills, critical thinking, time-management and strong relatioship-building skills. Conducts telephonic screenings based on criteria, refers patients to healthcare programs, specialists and other multidisciplinary team members such as a diabetes health educator, home visit provider, geriatric clinic, home health, pharmacist, etc. As per guidelines and or red flag criteria escalates to the RN or SW or supervisor when patient needs or concerns are beyond his/her scope of practice. Assist patients and or caregivers in achieving compliance and improving adherence to plan of care notifying RN/SW or provider of issues and collaborating with multidisciplinary team members (primary care physician, social workers, pharmacists, home visit providers, etc) based on the patient's established plan of care. Coach's patients, family and/or caregivers about the disease process including how to recognize signs and symptoms of worsening disease and next steps. Based on care plan or program criteria, identifies appropriate cases to discontinue from the program and collaborates with SW and RN to document rationale accordingly. Serves as an advocate and liaison between patient/family and physician, hospital staff, members of the health care team, clinic care coordinators, and community resources. Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments. Assists patients with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures, escalating patients as per scope of practice. This position is work from home in California , with a preference for candidates residing in the Ventura region.

Requirements

2 years relevant experience or advanced degree required.
Graduate of an accredited LVN school.
Clear and current CA Licensed Vocational Nurse (LVN) license.
Excellent computer skills and ability to learn new systems
Strong organizational (time management) and interpersonal skills
Ability to handle multiple priorities with strong attention to detail
Ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word
Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)
Ability to work autonomously within a matrix environment without direct supervision or support

Nice To Haves

Previous care coordination experience strongly preferred.
5+ years experience preferred.
Disease management experience a plus.
Proficiency with EHR's a plus.
Experience with Google Workspace a plus.
Bilingual in English/Spanish preferred.

Responsibilities

Perform patient care management services that support the established plan of care as directed by the other licensed staff within the department.
Assist in relaying instructions from the physician to a patient or authorized person
Collect patient data, documenting patient concerns, patient messages, and any instructions or education provided within the care management operational platform.
Provide leadership to support staff.
Conducts telephonic screenings based on criteria, refers patients to healthcare programs, specialists and other multidisciplinary team members such as a diabetes health educator, home visit provider, geriatric clinic, home health, pharmacist, etc.
Escalates to the RN or SW or supervisor when patient needs or concerns are beyond his/her scope of practice.
Assist patients and or caregivers in achieving compliance and improving adherence to plan of care notifying RN/SW or provider of issues and collaborating with multidisciplinary team members (primary care physician, social workers, pharmacists, home visit providers, etc) based on the patient's established plan of care.
Coach's patients, family and/or caregivers about the disease process including how to recognize signs and symptoms of worsening disease and next steps.
Identifies appropriate cases to discontinue from the program and collaborates with SW and RN to document rationale accordingly.
Serves as an advocate and liaison between patient/family and physician, hospital staff, members of the health care team, clinic care coordinators, and community resources.
Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments.
Assists patients with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures, escalating patients as per scope of practice.