Licensed Vocational Nurse Care Coordinator - Population Health Admin

Description Summary: Provides care under the direct supervision of the Population Health Director of Care Management or Nurse Manager utilizing physician approved patient protocols according to established standards and best practice guidelines. Facilitates the communication between patient/caregiver, physician and the outpatient care team to optimize health and wellness, reduce inpatient admission, reduce re-admissions and improve medical stability in the patient population served. Works collaboratively with Nurse Navigators to manage medical stability in patients with high risk disease management with complex comorbid conditions. Responsibilities:

• Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team.
• Works in collaboration with the PCMH Team in the design, implementation and evaluation of the PMH model as applicable.
• Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers.
• Reviews patient medical record to identify care gaps.
• Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter.
• Fosters a Team approach by working collaboratively with the member, family, PCP and other members of the healthcare team to ensure coordination of services.
• Assists Nurse Navigators? in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines.
• Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing.
• Facilitates a collaborative approach with care team for identification of and closure of care gaps.
• Utilizes educational and behavioral change strategies to promote patient collaboration with the care team.
• Incorporates excellent written, verbal and listening communication skills, positive relationship building skills and problem solving into patient care coordination practice.
• Performs duties as required or assigned for specific operational purposes for which they are qualified to perform.
• Maintains all professional CEU?s in compliance with State and Regulatory requirements.
• Maintains confidentiality in all areas at all times.

Requirements:

• Basic LVN Nursing skills
• Knowledge of lab procedures and diagnostic testing
• Ability to write clear documentation and ability to write detailed specifications
• Solid organizational skills including attention to detail and multi-tasking skills
• Basic computer skills
• EMR Experience
• 3 years clinical experience with at least 2 years in a primary care clinic preferred
• LVN/LPN License in the state of TX or where positions is located within the enterprise
• BLS Certification, if applicable

Work Schedule:
8AM - 5PM Monday-Friday Work Type: Full Time

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CHRISTUS Health is an international faith-based, not-for-profit health care system based in Irving, Texas, with more than 60 hospitals in Texas, Louisiana, New Mexico, Chile, Colombia and Mexico. CHRISTUS Health is made up of 50,000 Associates providing compassionate and individualized care at more than 600 centers, including community hospitals, clinics, long-term care facilities and health ministries. Sponsored by the Sisters of Charity of the Incarnate Word of Houston, Sisters of Charity of the Incarnate Word of San Antonio and the Sisters of the Holy Family of Nazareth, our mission is to extend the healing ministry of Jesus Christ to every individual we serve.

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