CTO Care Coord LPN (Baltimore, near Franklin Square Medical…

Associate’s Degree from National League for Nursing accredited program, or Diploma from National League for nursing accredited program.

3 years work experience including 1 or more years of proven case management project management and population health coordination experience. Experience with data collection and reporting preferred. Community Outreach experience, preferred. Familiarity with the local area and/or Population Health workforce integration. Experience working in an ambulatory setting preferred.

Valid Maryland LPN license required.

Effective verbal and written communication skills. Excellent interpersonal and customer service skills especially serving geriatric patients. Strong analytical and critical thinking skills. Strong community engagement and facilitation skills. Advanced project management skills. Commitment to collective impact concepts. Flexibility and the ability to work autonomously as well as take direction as needed. Cultural competency. Proficient computer skills along with experience using Microsoft applications-Word, Excel, etc. and familiarity with entering data in an electronic medical record (EMR).

In collaboration with the interdisciplinary care team, acts as primary care team agent for the coordination of care for a panel of attributed Medicare beneficiaries by ensuring the following: Ensures attributed beneficiaries have timely access to care (same day or next day access to the patient’s own practitioner and/or care team for urgent care or transition management); Facilitates use of alternatives for care outside of the traditional office visit to increase access to the care team and the practitioner, such as e-visits, phone visits, group visits, home visits, and visits in alternate locations (senior centers, assisted living) captured in the medical record; Assists patients with scheduling appointments with providers including annual wellness visits. Attributed beneficiaries receive a follow up interaction from the practice within 2 days for hospital discharge and within one week for Emergency Department (ED) discharges; Coordinates referral management for attributed beneficiaries seeking care from high-volume and/or high-cost specialists as well as EDs and hospitals; Facilitates connection to services for patients who may benefit from behavioral health services, including: patients with serious mental illness; patients with substance use disorders’ patients with depression, anxiety, or other mental health conditions; patients with behavioral and social risk factors and BH issues; patients with multiple co-morbidities and BH issues; Assists with identifying patients to participate in the Patient-Family/ Caregiver Advisory Council (PFAC) and help to organize and facilitate the PFAC annual meetings; Engages attributed beneficiaries and caregivers in a collaborative process for advance care planning (MOLST, Advanced Directives, Proxy) and directs patients in self management care for high risk conditions and high frequency conditions.

Builds and maintains relationships with practice staff, interdisciplinary care team and community resource partners.

Ensures daily telephonic patient communication to help to close gaps in care and provide up-to-date healthcare information helping to facilitate the members understanding of his/her health status using available reports including quality m page and HIE CRISP to ensure relevant medical history/encounter are accessible in EMR.

Facilitates ongoing communication amongst practice and care team by participating in huddles, hosting regular conference calls, in-person meetings, or coordinating regular email updates to ensure alignment of activity, discuss new developments, and exchange information.

Performs analysis of attributed beneficiary data and presents data intelligently and creatively in a way that can be easily and quickly grasped by the practice and interdisciplinary care team as appropriate.

Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.

Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.

Performs other duties as assigned.