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Chronic Care Specialist- LVN Required

Company: Genesis Prime Care
Location: Texarkana
Posted on: June 24, 2022

Job Description:

Job DescriptionJob Summary Responsible for assisting Providers through the use of the electronic medical records to systematically identify patients and plans, manages and coordinates care, based on need. They must be able to gather all relevant information for a patient and deliver a care program that works best for each individual case. The Chronic Care Specialist works in collaboration and continuous partnership with chronically ill or "high-risk" patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:

  • Promote timely access to appropriate care
  • Increase utilization of preventative care
  • Reduce emergency room utilization and hospital readmissions
  • Increase comprehension through culturally and linguistically appropriate education
  • Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver (s)
  • Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
  • Increase patients' ability for self-management and shared decision-making
  • Provide medication reconciliation
  • Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs. Essential Duties and Responsibilities
    • Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
    • Work with patients to plan and monitor care:
    • Assess patient's unmet health and social needs
    • Assist with reviewing a care plan with the patient, family/care giver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
    • Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
    • Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time
      • Facilitate patient access to appropriate medical and specialty providers
      • Educate patient and family/caregiver(s) about relevant community resources
      • Facilitate and attend meeting between patient, family/caregiver(s), care team, payer, and community resources, as needed.
      • Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-and referrals
      • Assist with identification of "high-risk" patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EMR.)
      • Attend all Chronic Care Specialist training courses/webinars and meetings.
      • Provide feedback for the improvement of the Care Coordination Program. Knowledge, Skills and Abilities Required
        • Knowledge of protocols in general and an ability to quickly gain specific knowledge of the Clinic's current operational protocols
        • Knowledge of Family medicines terminology and appropriate abbreviations
        • Ability to read and comprehend short correspondence, and memos
          • Ability to document, with clarity, all information relevant to a patient's needs
            • Ability to effectively present information in small group situations to patients, Clinic staff, and the general public.
            • Ability to work cooperatively with community agency personnel to coordinate services for patients
            • Ability to use office equipment including but not limited to computers, fax machines, telephones and copiers
            • Ability to prioritize and allocate resources
            • Fulfills administrative duties.
            • Assists in maintaining an efficient, safe, secure, orderly, and aseptic environment of care for all patients and employees.
            • Is familiar with and abides by OSHA Standards, Hazardous Materials, Universal Precautions, use of personal protective equipment, Evacuation, Fire, Disaster, and Safety Plans.
            • If bilingual, translates in Spanish between non-Spanish speaking staff and Spanish speaking patients as requested.
            • Performs all other duties as assigned including but not limited to assisting in the role of LVN within the region when there is opportunity to do so. Credentials and Experience Required
              • Current Cardiopulmonary Resuscitation (CPR) Certification
              • Licensed Vocational Nurse
              • High School Diploma/GED Preferred
                • 3-5 years' experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.
                • Evidence of essential leadership, communication, education, and counseling skills
                • Proficiency in communication technologies (email, cell phone, etc.)
                • Experience with health IT systems and reports is desirable
                • Local knowledge about and connections to community health care and social welfare resources is desirable
                • Ability to speak a relevant second language is desirable.

Keywords: Genesis Prime Care, Longview , Chronic Care Specialist- LVN Required, Healthcare , Texarkana, Texas

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