Setting : Small Primary Care Clinic (NP, LPN, MA team)
About the Role
We’re seeking a Licensed Practical Nurse who thrives in a collaborative, patient-centered environment. This role is at the heart of ensuring patients—especially those with chronic conditions, recent hospital discharges, or complex needs—don’t fall through the cracks. You’ll connect the dots between patients, providers, and community resources to keep care continuous and outcomes strong.
What You’ll Do
Care Coordination & Navigation
Conduct pre-visit planning and outreach to close care gaps (A1C, screenings, immunizations).
Perform 24–72-hour post-discharge calls, medication reconciliation, and schedule follow-ups.
Manage referrals, prior authorizations, and coordinate with specialists and payers.
Develop, update, and track individualized care plans in the EHR.
Connect patients to community resources such as transportation and social services.
Perform health risk assessments and support remote patient monitoring.
Clinical Support (as needed)
Room patients, take vitals, and perform point-of-care testing (A1C, UA, Accu-Chek, hemoglobin / iron).
Assist with wound care, ear washes, Retinaview exams, and lab draws.
Communication & Problem-Solving
Triage inbound calls and escalate when appropriate.
Coordinate with labs, home health, and specialists while keeping patients informed.
Identify risks early and propose proactive solutions.
Quality & Documentation
Maintain accurate, timely EHR documentation.
Help refine workflows and dashboards that improve coordination and efficiency.
What Success Looks Like (First 90 Days)
95%+ post-discharge calls completed within 72 hours.