Patient-Centered Medical Home - LPN Care Coordinator - Presbyterian Home of Summerville

Job Description Summary

The role of the Patient-Centered Medical Home (PCMH) Care Coordinator is a nurse that works collaboratively with the physicians, staff and other health care professionals to actively facilitate health care delivery and promote care team communication for an assigned patient population ensuring appropriate care is provided.

Entity

MUSC Health Partners (MHP)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC000101 CFC PC Patient Care Medical Home CC

Pay Rate Type

Hourly

Pay Grade

Health-23

Scheduled Weekly Hours

40

Work Shift

Day (United States of America)

Job Description

• Identifying patients that qualify for care coordination: not meeting clinical goals and quality measures (i.e. hypertension and diabetic control) for patients, overdue for visits, labs, or referrals and arranging for follow-up services as appropriate, identifying gaps in care and respond with appropriate action to correct. TCM coverage as needed.

• Utilizes Epic registries and reports in accordance with process (i.e. CCM-weekly & daily, quality measures, etc.) to identify patients and needs.

• Outreach to patients identified for care coordinator services (i.e. CCM, quality measures, etc.)  & documents attempt (s) & completion

• Schedule services and places referrals in accordance with patient needs (i.e. vaccine, labs, appointment, mammogram, etc.) 

• Follow up as appropriate to track data

• Accurately maintains 100% of data received.

• Communicates effectively and professionally  with patients, care teams and providers to provide support for continuity of care between patient, care team, and assigned providers 

• Compiles  and summarize information for quality measures and projects

• Attend 80 % of staff meetings

• Maintains communication with providers & care team members (I.e. Epic inbox message, email, phone, office schedule, in person)

• Identify patient needs and/or barriers (psychosocial and other) to care and coordinate patients/families contact with community resources.

• Completes & documents accurate information gathering of data

• Completes Epic & community referrals as needed

• Communicates & follow up of identified barriers to the appropriate care team member/resource

• Other duties as assigned

Additional Job Description

Education and Work Experience LPN:  Completion of a recognized Licensed Practical Nursing program. Ability to demonstrate commitment to patient centered care philosophy as evidenced by effective communications skills, professional demeanor, and excellent interpersonal skills.  Ability and motivation to articulate and support departmental philosophy of excellent guest relations. Must communicate effectively both verbally and in writing. Must be computer literate.

Licensures, Registrations, Certifications: LPN Required Licensure, Certifications, Registrations:  Licensed as an LPN within the state of South Carolina or a compact state. Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required.

Physical Requirements: Continuous requirements are to perform job functions while standing, walking and sitting. Ability to bend at the waist, kneel, climb stairs, reach in all directions, fully use both hands and legs, possess good finger dexterity, perform repetitive motions with hands/wrists/elbows and shoulders, reach in all directions. Maintain 20/40 vision corrected, see and recognize objects close at hand and at a distance, work in a latex safe environment and work indoors. Frequently lift, lower, push and pull and/or carry objects weighing 50 lbs (+/-) unassisted, exert up to 50 lbs of force, lift from 36” to overhead 25 lbs. Infrequently work in dusty areas and confined/cramped spaces. Ability/willingness to travel frequently to MUSCP-PC clinical locations away from the main campus.

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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