Care Management Coordinator / LPN JobFranklin, TN
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Why You'll Love This Job
Fast Pace Health strives to provide a best in class patient experience in every interaction. We are seeking a highly-skilled, experienced Care Management Coordinator / LPN to join our growing team. Our ideal candidate will be deeply committed to nurturing our Fast Pace mission of teamwork, communication, empowerment and quality care in a friendly and encouraging environment.
Fast Pace Health aims to push for a new vision of healthcare in rural communities that will consist of an array of different services. We are changing the delivery of healthcare in these rural areas by integrating excellent patient care, education, accessibility, and community service, in a way that puts the patient’s needs first and improves the health status of our communities.
The Care Management Coordinator/ LPN is a member of the chronic care management team, which is part of the Population Health Team that is under the leadership and direction of the Office of Medical Affairs. The Care Management Coordinator/ LPN reports to the RN Care Manager and will work closely with the Quality Coordinators and the Population Health Advocates. This is a fully remote role.
The Care Management Coordinator/ LPN acts as an educator, resource, and clinical advocate for patients and their families. of care management of Medicare high-risk patient populations with chronic conditions. The Care Management Coordinator/ LPN is an integral part of the Chronic Care Management (CCM) pod which consists of the RN CM and Care Management Coordinator LPN. The Care Management Coordinator/ LPN maintains patient-centered care by interfacing directly with patients and their families/caregivers in collaboration with physicians, the pharmacy team, the clinical team, the care management team, and other health care team members to improve overall health related outcomes as well as provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. The Care Management Coordinator/ LPN assists with goals setting and supports patients to achieve outcomes outlined within the patient’s comprehensive plan of care. The Care Management Coordinator/ LPN uses motivational interviewing techniques, is a problem solver, and empowers patients to improve their health related outcomes and overall wellbeing.
The expertise of the LPN is sought based on having a general understanding of chronic disease management, medication management, as well as having the skillset to treat the holistic needs of patients in order to empower the patient to achieve their highest level of function.
- Works under the direction of the RN Care Manager (CM) and in coordination with the Population Health and clinical team(s) across all FastPace primary care practice sites.
- Knowledge of patient care delivered in the ambulatory setting, valuing the vision, mission, and strategies of Fast Pace Population Health in offering value-based care by improving patient care, enhancing patient experiences, reducing healthcare costs, and improving provider satisfaction for stakeholders
- Ability to execute core care management duties as part of the CCM team:
- Identifies and engages appropriate patients for care management from lists, portals, and referrals, in collaboration with the care management team, clinical team, and with the support of the providers
- Assist patients and/or caregivers in scheduling patients’ appointments and access services as needed.
- Is an active member of the CCM team and collaborates with patient and care teams to support care gap closure.
- Works within the CCM team to support patients, family, caregivers, and other clinical team members in developing and implementing the patient’s care plan.
- Works under the direction of the RN Care Manager of the CCM team to collaborate with community partners, post acute care and home health services, social service agencies, caregiver programs, and durable medical equipment (DME) providers.
- Coaches and supports patients, under the supervision of the RN Care Manager (CM), with techniques and behavioral modifications in order to attain their goals. Incorporates shared decision making as part of the proactive support of the patient to achieve self-management goals
- Use motivational interviewing to promote behavioral change.
- Facilitates connections to community resources as directed by the RN Care Manager (CM).
- Cultivates positive relationships with all stakeholders, and members of the care team.
- Reinforces education with the patient, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and makes referral to appropriate Care Coordination services as needed.
- Fosters a team approach with all stakeholders by working collaboratively with the patient, family, Primary Care Provider, Pharmacy team, and other patients/members of the health care team to ensure coordination of services.
- Communication/ Outreach expectations include and are not limited to: care management team communication, telephonic outreach to patients and/ or the clinical team, digital communication and outreach (ex: text) to patients, notifications in the electronic medical record to applicable team members, payer interactions as appropriate, outreaches to community based organizations as needed.
- Escalates all urgent matters to the RN Care Manager (CM).
- Works closely with the Quality Coordinators, Population Health Advocates, Care Management and Medical Management teams to understand the patient’s entitlements and benefits.
- Maintains protection of sensitive Population Health Team information and follows all Fast Pace policies and procedures
- Maintains up to date knowledge on the latest information within each Value based care program to include and not limited knowledge to the Stars Rating Program, Quality Measures, and thresholds as established by payers and other contracting entities.
- Completes in a timely manner all mandatory compliance and employee related trainings
- The ability to build and maintain confidence and credibility with all employees.
- The ability to maintain friendly, cordial relations with all clients and employees; maintain a positive work atmosphere by acting and communicating in a manner that results in a positive work relationship with customers, co-workers and managers.
- The ability to perform the physical duties, use of senses, cognitive, and environmental functions of the position, as specified on the physical demands.
- Ability to comply with Company standards of operation and adhere to the Core Values of the Company, of teamwork, communication, empowerment, quality of care, and friendliness.
- Maintains required documentation for all care management activities. Collects required data and utilizes this data to adjust the treatment plan when indicated
- Participates in quality improvement activities as required.
- Attends in person-meetings when needed and ensures appropriate clinical management information is shared timely (under the supervision of the RN Care Manager) with patients, providers, clinical team(s), and the Population Health team in accordance with privacy standards.
- Supports newly hired Care Management team members as needed.
- Work with teams across the company to support their key processes or areas for improvement, as needed.
- Maintains professionalism and utilizes appropriate conflict resolution, assertiveness, negotiation, and collaboration skills in facilitating patient/member throughout the health care continuum
- Working knowledge of and experience with Electronic Health Records (EHRs)
- Maintains a working knowledge of applicable Federal, State, and local laws and regulations, FastPace policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
- Maintains licensure and continuing education in accordance to scope of practice requirements for LPNs
- Knowledgeable in the basic concepts and principles of Care Management, risk stratifying principles for population health, health status indicators, and is familiar with developing strategies that improve population health outcomes.