CHRONIC CARE COORDINATOR, LPN

Chronic Care Coordinator, LPN at AllCare Health with thhe Population Health Department in Grants Pass, Oregon

We Are Seeking Qualified Candidates to Join Our Team!

AllCare Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

Summary of the Position

This position is responsible for delivering evidence-based wellness promotion and self-care management solutions to all AllCare Medicaid, Medicare, and Medicare dual eligible members of all ages who have chronic diseases or conditions by performing the following duties.

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Essential Duties

1. Assessment, planning, implementing, coordinating and requesting services required to meet member’s health care needs.  2. Acts as an advocate and facilitates collaboration with the interdisciplinary care team (ICT) in order to assist members to develop a knowledge base that will allow self-reliance in coping with chronic illnesses. 3. Conducts thorough planning to determine and document specific objectives, goals, and actions to meet the member’s identified needs, including re-evaluation of the individualized care plan (ICP).

Job Duties

* Serves as subject matter expert in care coordination and case management interpreting regulatory requirements and coordinates the process to support those requirements. * Completes thorough assessments to collect in-depth information about member situations in order to identify their individual needs. * Develops a comprehensive case management plan based on initial assessment and adjusts as necessary. * Implements plans by executing and documenting specific interventions, activities and/or tasks that will lead to accomplishing the established goals. * Organizes, establishes, integrates, updates, modifies and documents the resources necessary to accomplish the goals established in the care management plan. * Continues to gather information from all relevant sources and documentation and determines the plan’s effectiveness. * Evaluates the plan at appropriate intervals to determine the care management plan’s effectiveness in reaching the goals and outcomes and modifies as necessary. * Determines outcomes by measuring the interventions in order to determine the effectiveness of performing case management.  * Delivers condition specific education in accordance with established standards of care, and based on clinical practice guidelines. * Documents the complete spectrum of patient interaction, from a disease specific health assessment to completion of goals. * Participates regularly in Interdisciplinary Care Team (ICT) meetings regarding complicated cases in progress. * Seeks out and solicits the help of all health care providers and community agencies associated with the case in order to secure appropriate resources for the member.  * Maintains caseload of high risk/high cost members having designated chronic conditions, in accordance with department policy.  * Assesses member learning style and develops a teaching program appropriate to reading and comprehension skills of clients.  * Helps members choose actions that will bring goals and objectives to completion in a timely manner. * Collaborates with providers of care to ensure appropriate access to services and follow up on the results of referrals.  * Assists as needed in quality initiatives for the department. * Coordinates care needs for the Dual Special Needs Population (DSNP) member to ensure compliance with the Special Needs Model of Care (SNP MOC). * Prepares for and participates in all required DSNP trainings, education, and member audits. * Participates in initial, annual, and ongoing trainings. * Acts as preceptor during the onboarding of new hire employees. * Maintains punctual, regular and predictable attendance.  * Works collaboratively in a team environment with a spirit of cooperation. * Respectfully takes direction from care coordination leaders. * Meets all required training including those listed in Relias Learning Module System (LMS). * Other duties as assigned.

On Call Responsibilities 

This position does not have any on call responsibilities. 

Supervisory Responsibilities 

This position does not have any supervisory responsibilities.

Clinical Supervision

This position receives clinical supervision from an assigned clinician. Supervision needs will be evaluated based on clinical experience and performance.

Job Requirements

May require the use of personal vehicle for local travel (subject to mileage reimbursement).

Education

Associate's degree (AA) from a two-year college or technical school required.

Experience

* One to two years related experience and/or training in underserved populations with demonstrated experience working with diverse populations in community settings.. * Two to four years related experience and/or training in Case Management, Care Coordination, Managed Care, or Homecare Coordination, or as a registered CSWA (Clinical Social Work Associate). 

Certificates, Licenses, and/or Registrations 

* Valid Oregon Driver’s License and vehicle insurance.  * Current Basic Life Support (BLS) Certification or willingness to be certified within 90 days of hire. * Current Verbal De-escalation (CPI) Certification or willingness to be certified within 90 days of hire. * Current Mental Health First Aid Certification or willingness to be certified within 90 days of hire. * Valid Oregon LPN Licensure * CCM certification preferred or successfully completing the certification within two years of employment.

Technical Skills

* Familiarity with the Healthcare industry. * Excellent organization and time-management skills. * Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel). * Knowledge of and compliance with HIPAA regulations. * Excellent at identifying and implementing improvement activities and ensuring excellence.  * Excellent at locating information and synthesizing information from various sources. * Knowledge of customer service and service recovery best practices. * Excellent customer service skills to respond appropriately and interact positively with upset customers. * Knowledge of phone customer service best practices and experienced with multi-line call centers. * Knowledge of the ways implicit bias, personal identity, and power and privilege impact individuals, organizations and systems. * Knowledge of the widespread impact of trauma and paths for recovery * Excellent at recognizing the signs and symptoms of trauma in patients, families, and staff; and actively avoid re-traumatization

Interpersonal Skills

* Demonstrate accountability, inspiring trust and confidence from others. * Self-resolve most conflicts or misunderstandings with minimal need for direct supervision. * Work with high initiative, energy and effectiveness in a fast-past environment. * Effectively and professionally communicate with team members and customers. * Collaborate within a multidisciplinary, diverse team to provide professional service. * Interact positively with customers to satisfy needs and resolve problems in a pleasant and professional manner. * Prioritize and organize work according to competing timelines. * Allocate your time so that you can complete tasks within established deadlines. * Adapt to change, learn quickly, and work with ambiguity.  * Use creativity and resourcefulness to solve new problems. * Cope and self-manage during stressful situations. * Maintain an attentive and empathetic demeanor. * Maintain a high degree of professionalism and confidentiality. * Effectively work with people with mental illness and from diverse backgrounds and experiences. * Provide respectful and understanding service to customers within a multicultural environment. * Create a pleasant experience for all customers, such as being personable and at