Care Coordinator/LPN

Job Title: LPN/Care Coordinator
Pay Range set to $22 - $33 per hour.
Department: Clinical
About TCA
TCA Health, a Federally Qualified Health Center located on Chicago's far south side has been a provider of innovative, accessible, and quality primary care, dental, behavioral health services and more to Chicagoland's underserved communities for over 50 years! The culture at TCA Health is one of service and commitment. Our team of dedicated professionals is the reason why TCA Health continues to be one of Chicago’s leading Federally Qualified Healthcare Centers.
TCA VALUES
TCA C.A.R.E.S.

Compassion: We are kind, considerate, and caring.
Accountability: We take ownership for each person’s experiences.
Respect: We treat each person with dignity.
Excellence: We seek the highest level of performance in all we do.
Stewardship: We strive for racial and health equity, diversity, and inclusion by delivering quality health care and access for all.

Position Summary
The Care Coordinator/LPN will be responsible for monitoring and coordinating population- health management activities at one or more health center locations. The primary function of this position will be to work in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver 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, promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver. Using a team-based approach, the care coordinator will act as a resource to patients and health care staff to ensure patients receive all the care and services they require. Care Coordinators must be proactive, well-organized, present a friendly demeanor and function well in a fast-paced clinic environment. This person may be assigned to School Based Health Activities as well to assist in transitions of care for students leaving the umbrella of school-based health care into community healthcare. They will ensure that students have the information and resources for continuity and management of their condition into the next setting.
ESSENTIAL DUTIES AND RESPONSIBILITIES (Included but not limited to the following).

Identify patients for care coordination via generating patient registries, MCO care gap lists, Medical Home Network (MHN) portal, etc.
Conduct timely patient outreach/engagement and follow up activities, via telephone, direct mailing, face-to-face and/or electronically, to new and established patients and to schedule coordinate appointments as needed.
Track, monitor, and schedule follow-up appointments for patients recently discharged from the hospital or ER; collaborate with care team for patient needs.
Assist patients in collaboration with care team, with transitions to care, navigating health care services and linkage to community resources and support.
Regularly collaborate, coordinate, and communicate with care team member(s) to resolve outstanding patient care related items (care gaps; outstanding referrals, follow up paperwork etc.)
Assist with data collection and reporting for targeted clinical quality measures.
Assist with closing the loop on outstanding referrals, diagnostic results (i.e. labs, x-rays, etc.) patient documents and consult reports by following up with patients, specialty providers, hospitals, health plans, community agencies, etc.
Provide patient education resources to assist the patient with self-management needs.
Serve as a resource to the care team and other staff members on the collection and management of population data, patient outreach, tracking of patient progress, and generation of reports.
Collaborates with nursing staff (RN’s/LPN’s) to identify and refer appropriate patients for complex care management.
Monitors clinical quality measure outcomes and identifies opportunities for improvement in collaboration with Director of Clinical Quality.
Produce, maintain and input timely, accurate, and thorough documentation of all communication directly with and on behalf of patients with the EHR; including consultations/scheduling regarding patient care/services.
Maintain confidentiality of all medical records by adhering to HIPAA guidelines when handling patient information and sensitive documents.
Implement and maintain department’s process for logging/tracking all patient outreach efforts made (i.e. appointment scheduling).
Timely and accurate completion of all care coordination tasks and assignments by deadlines.
Provide back up support and assistance with care team activities (i.e. referral functions) as needed and assigned.
Maintains professionalism at all times when communicating with patients, staff members, community partners, external agencies, etc.
Adhere to all policies, procedures, and protocols of the agency and department.
Participate and adheres to NCQA Patient Centered Medical Home (PCMH) standards and quality improvement (Q.I.) related activities as assigned.
Participate in chart audits and reviews as needed and assigned.
Attends meetings and trainings as scheduled.
Meet individuals and department targeted productivity goals, objectives and performance ratings.

Education And Experience

LPN Illinois licensure or equivalent from an accredited school/program required.
Prior experience as an LPN is strongly preferred; experience as an EMT, CNA, M.A. or community health worker is also a plus.
Prior work experience in a clinic, hospital or health care agency setting preferred.
Knowledge of medical terminology and systems a plus. Must be detail-oriented, organized and have the ability to multi-task and work in a fast-paced environment.
Knowledge of insurance authorization process for Medicaid/Medicare and private commercial insurance.
Must possess excellent customer service and writing skills.
Position requires computer literacy; prior electronic health records (EHR) experience strongly preferred.

CERTIFICATES, LICENSES, REGISTRATIONS
LPN licensure, or Medical Assistant Certification of Training from an accredited school or association and current CPR/AED certification required.
Qualifications
To perform this job successfully, an individual must demonstrate the following qualifications:
Able to work independently.
Able to work and communicate well with all age groups
Flexible work schedule to meet clinic hours.
Willing to travel to school-based clinic, meetings and other satellite sites as necessary.
Able to adapt to change and maintain a professional demeanor.
Able to handle a fast-paced diverse workplace in a team environment.
Excellent interpersonal/oral communication skills and organizational and typing skills preferred.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to walk and stand regularly.
Required to be able to type proficiently, write legibly and read a computer monitor, as well as printed or handwritten materials.
Needs to be able to communicate and respond effectively.
Occasionally may need to crouch, kneel, stoop or bend.
Must be able to use fingers, hands and arms extensively to draw blood, administer injections and attend to other aspects of patient care.
Ability to assist with moving or lifting equipment and patients up to 50 pounds
Visual acuity to perform tasks requiring close vision and ability to adjust focus.
Ability to travel to the School Clinic.
WORKING CONDITIONS
Clinical Setting.
OSHA – Highly likely to produce blood or body fluid exposure.