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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: Exempt position 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 programs within scope of a state of Missouri Licensed Practical Nurse (LPN) and provides assistance to and direct supervision of team members functioning in roles of care management and in support of PCHH and related programs.

Essential Job Responsibilities:

1. Direct relationships with patients and coordination with primary care team, specialty care teams, and inpatient facilities.

1. Develop care plans, monitor medication adherence and reconciliation, identify and address high utilizers.

1. Must know and adhere to the Mission, Vision and Values of Four Rivers Community Health Center.

1. Utilize critical thinking skills to interpret and act in accordance with Four Rivers Community Health Center Mission, Vision, and Values in a variety of complex situations.

1. Demonstrates understanding of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and comply with patient information safeguard guidelines to protect patient information.

1. Demonstrate expert communication skills with patients, Four Rivers Community Health Center administrative and multidisciplinary team members, and community partners.

1. Use evidence-based guidelines, literature, program assistance letters (PALs), official manuals and regulations, and appropriate nursing assessments to assist in the coordination of care of individual patients and management of population health to include but not limited to social determinants of health (SDOH), chronic disease management, ER utilization and hospital admissions.

1. Be proficient at utilizing the EHR, DRVS, Cyber Access, eMOMED, Health Information Exchange (HIE) connected portals, and other applicable data sources to obtain patient information for coordination of care and evaluation of effectiveness of all population health related programs.

1. Utilize afore listed data repositories (Item 7.) to extract, analyze and interpret data to evaluate and address care gaps and affect positive patient outcomes for population health programs.

1. Participate and lead quality improvement initiatives associated with population health, quality measures for various organizations and required compliance (MPCA, MCO's, HEDIS, UDS).

1. Must provide the highest level of customer service striving to provide a patient experience that is keeping with Four Rivers Community Health Center core values and as outlined by AIDET.

1. Other duties as assigned.

Qualifications:

1. 1. Education: Must have an LPN license in the state of Missouri
2. 2. Experience: Minimum three years of experience as a LPN and one year of case management, care coordination, or program management preferred.
3. Transportation and Travel Requirements: Must have reliable transportation and be able to attend off site training, attend off site meetings, and work nonstandard hours as required to accomplish the duties of this position.

Performance Requirements:

1. 1. Develop and oversee care management of PCHH Patient Population.
2. Assist other members of the population health team.
3. Assist any Four Rivers Community Health Center team members with issues that arise regarding population health procedures.
4. Follow Federal, State of Missouri and agency policies regarding care coordination and healthcare process navigation for all Four Rivers Community Health Center patients in accordance with HRSA, NCQA and specific requirements of managed care programs.
5. Ensure SDOH of patients have access to resources to include shelter, transportation, food, medical and dental care, and provide and/or directly supervise team members assisting with SDOH and providing care coordination.
6. Conduct and oversee the in-person, phone, and virtual visits for patients/clients contacted as part of PCHH within a timely manner per Four Rivers Community Health Center procedures, and specific contract or managed care organization requirements ensuring accurate documentation of all patient contact in the EHR.
7. 7. Monitor and assist with all patient care coordination activities during treatment at Four Rivers Community Health Center facilities or in the community.
8. 8. Attend a reasonable amount of Four Rivers Community Health Center and community partner sponsored events within a calendar year.
9. 9. Conduct staff meetings or give public presentations as needed.