Chronic Care Lpn

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About Us:

Healthy Home Primary Care is dedicated to providing high-quality, compassionate care to our patients, primarily an elderly population. We are a patient-centered practice that values teamwork and strives to make a meaningful impact in the lives of those we serve.

Job Summary:

At Healthy Home Primary Care, we are looking for a dedicated and personable Licensed Practical Nurse (LPN) who will lead our CCM programs that focuses on patients who have multiple (two or more) chronic conditions that are expected to last at least 12 months or more. We provide an essential service that helps providers stay in touch with and meet their patients’ healthcare needs in between office visits.

The role of an LPN Personal Care Coordinator is to care for patients in our program while working in conjunction with the patient’s care team to facilitate and address existing and new chronic health issues through outbound phone calls. This position also focuses on assisting patients in obtaining the resources they need to improve their health, happiness, and longevity.

We are looking for nurses who are passionate patient advocates who want to form ongoing, collaborative relationships with their patients to improve their lifestyles for the better.

Key Responsibilities:

• Conduct thorough patient assessments to develop individualized care plans that address complex chronic conditions.
• Provide ongoing patient education on disease management, medication adherence, lifestyle modifications, and self-care techniques.
• Coordinate with physicians, specialists, and community resources to ensure seamless delivery of care and appropriate follow-up.
• Utilize electronic health record (EHR) systems such as Intergy to document patient interactions accurately and efficiently.
• Monitor patient progress through regular check-ins via phone calls or telehealth platforms, adjusting care plans as needed.
• Assist with medication management, including administration of injections and IV infusions when appropriate.
• Support patients with comorbidities such as diabetes, hypertension, cardiac issues, or respiratory conditions by providing targeted interventions.
• Ensure compliance with HIPAA regulations and maintain meticulous medical documentation to uphold confidentiality and legal standards.

Other Responsibilities

• Patient Intake: Room patients, reconcile medications, collect medical history, take vitals, and complete screening questionnaires.
• Care Coordination: Triage phone calls and collaborate with providers to ensure patients receive appropriate and timely care.
• Patient Follow-Up: Call patients to address clinical concerns, provide lab/imaging results, and offer continued support.
• Transitional Care Coordination: Monitor hospitalization records, request records, and set up appointments as necessary.
• Phlebotomy & Specimen Processing: Perform blood draws, draft lab orders, and process specimens.
• Provider Support: Assist providers with medication refills, imaging orders, and other tasks as directed.
• Pre-Operative Coordination: Ensure pre-op clearance by ordering necessary labs and imaging.
• Preventative Care: Close HEDIS care gaps by coordinating preventative medicine and care plans with patients.
• Point-of-Care Testing & Procedures: Perform injections (subcutaneous/intramuscular), nebulizer treatments, and other point-of-care testing as directed by the provider.

Requirements

• Valid nursing license with current registration in the relevant state or region.
• Proven experience in chronic disease management within settings such as primary care, long-term care facilities, or home health environments. (preferred)
• Familiarity with EMR/EHR systems for documentation and case tracking.
• Strong clinical skills including vital signs assessment, medication administration, aseptic technique, and wound care.
• Knowledge of ICD-10 coding standards for accurate documentation and billing purposes.
• Experience working with diverse populations including elderly patients in assisted living or nursing homes.
• Ability to perform comprehensive patient assessments and triage effectively in fast-paced environments.
• Excellent communication skills to educate patients and collaborate effectively with multidisciplinary teams across the practice and local healthcare facilities.

Skills & Abilities:

• Personable and compassionate with a strong desire to work with an elderly population.
• Excellent communication skills with the ability to engage patients in a warm, respectful manner.
• Strong problem-solving skills and ability to work independently and as part of a team.
• Dependable and trustworthy with a commitment to showing up every day and ensuring the job gets done.
• Strong organizational skills and ability to multi-task in a fast-paced environment.
• Familiarity with HIPAA regulations and maintaining patient confidentiality.

Work Hours:

Monday through Friday, 8 a.m. – 5:30 p.m.

Normal hours are 40/week.

This job description is intended to convey information essential to understanding the scope of the position and is not an exhaustive list of skills, efforts, duties, responsibilities, or working conditions associated with it.

Pay: $26.00 - $30.00 per hour

Benefits:

• Paid time off

Work Location: In person