LPN Care Coordinator

Support physicians, mid-level providers, and nurses in delivering patient care within a clinic environment. Assist patients who call the clinic. Serve as an essential member of the interdisciplinary care team, delivering high-quality care to patients both in-person and through telephone and EHR portal communications in a timely manner.

This position will also be responsible for assisting with Chronic Care Management (CCM), Transitional Care Management (TCM), and Remote Patient Monitoring (RPM).

Position

Graduate of an accredited School of Practical Nursing (LPN) program Strong communication and customer service skills are essential for success. Thorough knowledge of disease processes to ensure appropriate triage and care for patients. Comprehensive understanding of healthcare practices and protocols. Excellent computer skills, preferably with experience using electronic health record (EHR) platforms. Knowledge of CMS guidelines and documentation requirements for Chronic Care Management, Transitional Care Management, and Remote Patient Monitoring preferred. Experience with care coordination, chronic disease management, population health, or value-based care preferred.

A minimum of three years’ experience in a clinical setting.

Licenses/

WV licensure as a Practical Nurse Current BLS Certification.

Job

Provide direct care to patients as assigned and qualified to perform while under the direction of a nurse, physician orders, or established protocols. Answer phones courteously, assisting patients with healthcare inquiries, and handling upset patients with de-escalation techniques. Document all phone interactions, including attempted calls, in patient charts.

Conduct phone interviews to gather necessary information for providers. Schedule patient appointments promptly and return calls by the end of the day. Welcome patients warmly, addressing concerns and easing anxiety.

Triage patients based on care urgency and clinic protocols. Record vital signs accurately and update patient histories. Conduct initial patient assessments and participate in patient education.

Maintain accurate patient records and complete charting promptly. Process stat referrals efficiently. Assist with patients enrolled in Chronic Care Management (CCM) programs, including monthly patient outreach, care plan development and updates, medication reconciliation, goal setting, and documentation in accordance with program requirements.

Assist in performing Transitional Care Management (TCM) activities, including timely post-discharge patient outreach, medication reconciliation, coordination of follow-up appointments, patient education, and communication with providers and community resources. Assist with monitoring and managing patients enrolled in Remote Patient Monitoring (RPM) programs by reviewing transmitted physiologic data, identifying abnormal findings, notifying providers of significant changes, providing patient education, and documenting interventions. Coordinate care among primary care providers, specialists, hospitals, home health agencies, pharmacies, and community resources to promote continuity of care and reduce hospital readmissions.

Maintain accurate and timely documentation to support CCM, TCM, and RPM services, ensuring compliance with CMS, payer, and organizational requirements. Participate in quality assurance and patient care meetings. Other duties as assigned.

All employees are required to adhere to WVSOM Health's high standards of customer service excellence.

The WVSOM Health Clinic is a Rural Health Clinic accredited by the NCQA as a Patient-Centered Medical Home - Level 3. WVSOM Health, located in historic Lewisburg, WV, offers Quality Healthcare... Close to Home.

We are located on the campus of the West Virginia School of Osteopathic Medicine (WVSOM). As a comprehensive not-for-profit health care organization, we are committed to providing quality primary health care to the residents of the greater Greenbrier Valley and surrounding areas. In addition to serving the local communities, WVSOM Health serves as a primary clinical training site for WVSOM students, interns, and residents. We offer a wide range of primary care services, including medical acupuncture, diabetic education, acute care, family medicine, psychology, internal medicine, osteopathic manipulative medicine, pediatric medicine, proctology, mental health, and radiology.

Employment at WVSOM Health is contingent upon the timely and successful completion of a post-offer drug screen, U. S. Citizenship and Immigration Service’s I-9 form, and background investigation including but not limited to whether you have been sanctioned or excluded from participating in any Medicare, Medicaid, or other government-funded programs.

WVSOM Health is an Equal Opportunity Employer.