Overview Join to apply for the LPN Care Manager (Hybrid Remote) (Clay, Coosa, Randolph & Talladega Counties, AL) role at AltaPointe Health Systems .
This position is hybrid-remote and will require occasional work shifts in the office setting.
The Care Coordinator is responsible for ensuring linkages for CCBHC patients and the community to provide seamless transitions across the health services spectrum, including physical and behavioral health, and community services (e.g., social services, housing, educational systems, employment services, and other needed services) as needed to facilitate wellness and recovery of the whole person. The role is based on a person-centered plan of care as required by CCBHC. The Care Coordinator works collaboratively with clinical and non-clinical staff, external providers, and community resources to assist clients in overcoming barriers to care, improving health outcomes, and promoting overall well-being. The role requires patient-focused approach, strong organizational skills, and proficiency in managing patient electronic health records. Strong communication and problem-solving skills are essential.
Responsibilities Assess and re-evaluate patient needs using EHR data and additional tools to determine needs and preferences, communicating them to all treatment participants
Create an Integrated Care Plan in conjunction with the patient and/or caregiver
Ensure the patient understands the Care Plan and is equipped to follow it
Identify and address barriers that might impede the patient\'s ability to care for themselves
Assemble an appropriate team of professionals to assist in meeting patient needs, organize care activities, and share information among participants
Assist the patient/caretaker in navigating the health system and addressing insurance coverage issues
Update assessment and care plan at least every 90 days
Utilize the Integrated Care Plan to drive all activities and services
Provide information and feedback in daily Huddles regarding needs, plans/interventions/results
Research ways to meet needs and implement action steps, monitoring progress
Advocate on behalf of the patient
Follow up regularly with the patient to ensure needs are met and identify changes or compliance concerns
Consult with treatment team when noncompliance is found
Provide training on disease management and healthy living skills
Provide initial Diabetes Care Introduction
Provide support and education for patient and their support system
Facilitate securing/providing medical records when patient is in hospital, ED, etc.
Track and support patients when they obtain services outside the practice
Follow up with patients within a few days of an ED visit or hospital discharge
Communicate test results and care plans to patients/families
Collaborate with staff and outside sources in the delivery and arrangement of services
Recognize crisis states and know how to deescalate or resolve them
Demonstrate application of adult-specific competencies
Supervision and Consultation Seek supervision and consultation as needed
Accept and apply suggestions for improvement
Actively work to enhance skills
Clinical Record Keeping Document in a timely fashion per AltaPointe policy
Document clearly and concisely
Document legibly
Professional Conduct Treat patients with care, dignity, and respect
Respect privacy and confidentiality
Assist others as needed
Adopt a teamwork approach with coworkers
Administrative and Other Related Duties as Assigned Actively participate in Performance Improvement activities
Actively participate in AltaPointe committees as required
Complete assigned tasks in a timely manner
Follow AltaPointe policies and procedures
Attend appropriate in-services training and other workshops
Qualifications Alabama Licensed Practical Nurse (LPN) in good standing, with three years of nursing experience. Experience working with and accessing community resources; proficiency in accurate and timely documentation of care coordination in the electronic health record; demonstrated ability to work with multi-disciplinary teams; prior work with populations required by CCBHC is preferred; proficiency in managing multiple priorities.
Seniority level Mid-Senior level
Employment type Full-time
Job function Health Care Provider
Industries Hospitals and Health Care
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