Carolina Prime Internal Medicine, located in Wilmington, North Carolina
strives to provide individualized, compassionate care for our patients through. comprehensive preventive care; aggressive treatment of developing or existing conditions with the ultimate goal in providing quality aging. We are seeking candidates that display excellent teamwork, accountability and will successfully function within a high performing organization for a
LPN - Clinical Care Coordinator opportunity.
Position Duties
The LPN - Clinical Care Coordinators work in concert with the Primary Care Provider (PCP) and the community to coordinate a full continuum of health care services considering the patient’s unique social and cultural dynamics
- Assess patients for conditions and concerns that can be addressed through community care management
- Act as a liaison between the PCP, local Health Department (HD), Department of Social Services (DSS), local hospitals, and other community agencies by identifying, arranging, and coordinating physical and/or behavioral health care services in concert with the PCP
- Collaborate with network providers in assuring appropriate client management
- Build and maintain relationships with community service providers through collaboration, networking and educating at community functions
- Assist patients in addressing concerns as needed through referral for assessment, counseling and communication with healthcare team
- Maintain appropriate client documentation in the EHR
- Develop and implement individualized care management plans for identified clients
- Provide direct follow-up and outreach services via face to face encounter (provider office visit, or community encounter), phone or mail
- Educate clients and families on the importance of medical care management and the proper method to access care within the medical home environment
- Educate recipients about disease states to include medication adherence, prevention and risk factor reduction
- Ensure follow-up with hospital discharge instructions for high risk, high acuity, high cost recipients; ensure continuity of care
- Act as a liaison to providers to ensure the use of Evidence Based Practices
- Assist providers with coordination of services for high risk, high acuity, high cost recipients by implementing Evidence Based Practices
- Coordinate, develop and provide health care education programs and trainings
- Advocate for patients to receive services that will improve their health condition
- Assess patients’ plans of care for any duplicate or unnecessary services to control costs to payor
- Audit charts and compile data to support the disease centered initiatives
- Responsible for maintaining patient and family confidentiality in accordance with HIPAA
Other job duties as required to include clinical care of the patients such as vaccine administration, triage patient for office visit, assist provider as needed
