LPN Transitions Care Navigator
- Provide Education and Resources relative to the patient’s diagnosis and treatment plan
- Educate on disease process, goal setting and will monitor patients identified for wellness, transitions care, chronic care and high risk care management programs
- Provide teaching to patients/families related to patient’s diagnosis, pathology, medical and nursing treatment plans, discharge needs and health goals
- Identify possible problems that could lead to an emergency/crisis situation and takes appropriate action to de-escalate the potential for the situation to occur
- Identifying, facilitating and securing access to needed healthcare, social services benefits and community resources
- Using decision support tools and supervisory support to identify appropriate interventions and health care and social service needs
- Communicating with clients, their families and caregivers to support care plan goals and integrate care delivery
- Facilitating follow-up care after hospitalization or emergency room visit
- Track aftercare outpatient appointments following inpatient or acute levels of care
- Regularly coordinating and communicating with Care Team members on all care plan activities, including referrals, transition care planning, and follow-up tracking
- Working in collaboration with other care team members and care providers, including behavioral health, disease care management, home care, social work and community-based organizations, to help client achieve optimal health outcomes
- Collaborate with the payer systems and payer Care Coordinators on specific patient care needs
- Outreach to patients to ensure their compliance with treatment plans
- Meet with the team regularly to discuss improvement of outcomes and adjusting to the population’s need
- Maintains logs and other data bases regarding care coordination activities
- Licensed Practical Nurse (LPN) certification required
- At least 2 years’ experience in a healthcare setting, primary care experience preferred
- Medically-based clerical experience
- EMR/EHR (Cerner/PowerChart/Medent/HealthENet/HealthELink)
- Microsoft Office (Excel/Outlook/Word)
- Ability for Collaboration with Team
- Some Medical Terminology Preferred
- Excellent customer service skills-ability to understand/exceed customer expectations while demonstrating the highest standards of care, respect, & confidentiality
- Must be able to work independently/alone and demonstrate self-motivation
- Comfortable with regular patient interactions and discussions centered around medical practice education
- Knowledgeable on how to navigate all aspects of medical care and managed care system
- Excellent communication skills both verbal and written
- Ability to handle multiple task and priorities
- Exceptional organizational skills
- This is a hybrid position and candidates must reside in WNY to be considered.
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