Job Description

Work Schedule:

0800 to 16:30 Monday through Friday

Benefits

• Insurance: medical, prescription, dental, vision, life, disability
• Paid Time Off: vacation, holidays
• Retirement: 403(b) with match
• Education assistance & continuing education; many courses offered on-site at the hospital

Qualifications:

1. Current Michigan licensure as an LPN
2. Experience in caring for patients with chronic diseases is required
3. Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers if needed
4. Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
5. Prefer experience in clinical or community health, care coordination, case management, home health or behavioral health
6. Must be proficient in communication and computer technologies (email, cell phone, etc.)
7. Previous experience with health IT systems, ERMs and data reports

Responsibilities:

1. Provides a coordinated, strategic approach to detect early, assess, and manage effectively the chronically and/or mentally fragile patient population's unmet health and social needs
2. Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care
3. Provides effective communications to improve health literacy for patients/families
4. Coaches patients/families towards successful self-management of their chronic disease
5. Acts as liaison between PCP and Specialists on patient condition as needed between office visits
6. Develops a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan
7. Monitors patient adherence to plan of care and progress toward goals, and facilitates changes as needed
8. Promotes healthy behaviors in all populations and ensures navigation assistance with community resources
9. Assists in outreach to patients made after they have been seen in ED or inpatient stay
10. Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator)
11. Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
12. Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources
13. Enrolls patient in Medicaid and assists with other community resource referrals
14. Ensures effective tracking of test results, medication management, and adherence to follow-up appointments
15. Facilitates and attends meetings between patient, families, care team, payers, and community resources
16. Ensures all VBR and MSSP metrics are met
17. Assists with VFC (Vaccines for Children) immunization programming at current Primary Care sites

Equal Opportunity Employer