LPN Nurse Care Manager

Job Title : LPN Nurse Care Manager

Department : Clinical Services

Status : Exempt

Immediate Supervisor Title : RN Population Health Programs Director

Job Supervisory Responsibilities : none

General Summary : Exempt position accountable to the RN Population Health Programs Director . R esponsible for development and care management of Primary Care Health Home patients . Perform s all duties required of this programs within scope of a state of Missouri Licensed Practical Nurse ( LPN) and provides assistance to and direct supervision of team members functioning in roles of care management and in support of PCHH and relat ed programs .

Essential Job Responsibilities :

• Direct relationships with patients and coordination with primary care team, specialty care teams, and inpatient facilities.
• Develop care plans, monitor medication adherence and reconciliation, identify and address high utilizers.
• Must know and adhere to the Mission, Vision and Values of Four Rivers Community Health Center.
• Utilize critical thinking skills to interpret and act in accordance with Four Rivers Community Health Center Mission , Vision, and Values in a variety of complex situations.
• Demonstrates understanding of the Health Insurance Portability and Accountability Act (HIP A A) of 1996 and comply with patient information safeguard guidelines to protect patient information.
• Demonstrate expert communication skills with patients, Four Rivers Community Health Center administrative and multidisciplinary team members, and community partners.
• Use evidence-based guidelines, literature, program assistance letters (PALs), official manuals and regulations, and appropriate nursing assessments to assist in the coordination of care of individual patients and management of population health to include but not limited to social determinants of health (S DO H), chronic disease management, ER utilization and hospital admissions.
• Be proficient at utilizing the EHR, DRVS, Cyber Access, eMOMED , Health Information Exchange (HIE) connected portals, and other applicable data sources to obtain patient information for coordination of care and evaluation of effectiveness of all population health related programs .
• U tiliz e afore listed data repositories (Item 7.) to extract, analyze and interpret data to evaluate and address care gaps and affect positive patient outcomes for population health programs.
• Participate and lead quality improvement initiatives associated with population health, quality measures for various organizations and required compliance (MPCA, MCO's, HEDIS, UDS).
• Must provide the highest level of customer service striving to provide a patient experience that is keeping with Four Rivers Community Health Center core values and as outlined by AIDET .
• Other duties as assigned.

Qualifications :

Performance Requirements :