Job Title: LPN Nurse Care Manager
Department: Clinical Services
Status: Exempt
Immediate Supervisor Title: RN Population Health Programs Director
Job Supervisory Responsibilities: None
General Summary: This exempt position is accountable to the RN Population Health Programs Director. Responsible for development and care management of Primary Care Health Home patients. Performs all duties required of this program within the scope of a Missouri Licensed Practical Nurse (LPN) and provides assistance to and direct supervision of team members functioning in care management roles in support of PCHH and related programs.
Essential Job Responsibilities:
Develop care plans, monitor medication adherence and reconciliation, identify and address high utilizers.
Establish direct relationships with patients and coordinate with primary care, specialty care teams, and inpatient facilities.
Adhere to the Mission, Vision, and Values of Four Rivers Community Health Center.
Utilize critical thinking skills to interpret and act in accordance with organizational values in complex situations.
Understand and comply with HIPAA regulations to safeguard patient information.
Demonstrate effective communication skills with patients, staff, and community partners.
Use evidence-based guidelines, literature, PALs, manuals, regulations, and assessments for care coordination and population health management, including social determinants of health, chronic disease management, ER utilization, and hospital admissions.
Proficiently utilize EHR, DRVS, Cyber Access, eMOMED, HIE portals, and other data sources for care coordination and program evaluation.
Analyze data from these sources to evaluate and improve patient outcomes and address care gaps.
Participate in and lead quality improvement initiatives related to population health and compliance with standards (MPCA, MCOs, HEDIS, UDS).
Provide high-level customer service, ensuring a positive patient experience aligned with Four Rivers core values and AIDET principles.
Perform other duties as assigned.
Qualifications:
Must hold an active LPN license in Missouri.
Minimum three years of LPN experience and one year in case management, care coordination, or program management preferred.
Reliable transportation and ability to attend off-site training, meetings, and work nonstandard hours as needed.
Performance Requirements:
Develop and oversee care management for PCHH patients.
Assist other team members with population health activities and issues.
Follow federal, state, and organizational policies regarding care coordination and healthcare navigation, ensuring compliance with HRSA, NCQA, and managed care requirements.
Ensure patients have access to resources addressing social determinants of health, including shelter, transportation, food, and medical/dental care, and supervise team members assisting with these services.
Conduct and oversee patient visits (in-person, phone, virtual) in a timely manner, documenting all contact accurately in the EHR.
Monitor and assist with patient care coordination during treatment at facilities or in the community.
Attend community events and conduct staff meetings or public presentations as needed.