Title: CCM LPN
Department: Care Coordination and Referrals
Reports To: Director of Care Coordination
EEOC: Administrative Support
FLSA Status: Non-Exempt
The Complex Care Management LPN will assist the care management team through direct and indirect response to the health care management issues and needs of CS-HHC patients/clients. Care Coordination/Management will include assisting Medical Providers, Behavioral Health Providers, Complex Care Managers, and Interdisciplinary Team members with clinical support services and data management. In addition they will assist clients with entitlement, resource and housing issues; referral management and follow-up; collection, recording, and review of client data; office, phone, clerical and other support services to care management team as needed.
CS-HHC’s Expectations of all Employees
- Adheres to all CS-HHC Policies and Procedures
- Conducts self in a manner that represents CS-HHC’s Values at all times
- Maintains a positive and respectful attitude with all work-related contacts
- Communicates regularly with supervisor about Departmental and CS-HHC concerns
- Consistently reports to work on time, prepared to perform the duties of the position
- Meets productivity standards and performs duties as workload necessitates
Essential Duties and Responsibilities
- Recieves complex care management referrals, assesses appropriateness for complex care.
- Works to provide and improve continuity the patient experience before, during, and following engagement within the health system.
- Assists in the development of a comprehensive complex care management plan, with particular emphasis on medically complex issues.
- Works with patient/caregiver/co-learner to develop goals, informs care team if inappropriate for complex care and makes recommendation for care plan in usual care teams.
- Provides clinical support and direct care management including patient education, goal setting, self management teaching and coaching for the high risk patients.
- Interacts with patients and patient caregivers as appropriate to ensure continuity of care, patient adherence to care plans, and identification of barriers preventing adherence to care plan.
- Coordinates care with other members of the care team to overcome any identified financial or social barriers that inhibit patients’ medical care.
- Works in coordination with the complex care management social worker.
- Provides care coordination/management services to individual clients, groups of clients, and/or families in the CS-HHC setting or general community, in a manner that is consistent with professional standards
- Records referral follow-up activity, progress and outcomes for the medical record.
- Gathers records and communicates referral and community resource developments.
- Attends and participates in team conferences as needed
- Assists client and care management team in obtaining and maintaining insurance, entitlement and other resource authorizations as needed to provide core health and behavioral health services and referral services
- Works with care management team to identify client/patient need for advocacy in the area of accessing health and behavioral health systems and services, entitlements and community resources
- Documents and communicates client needs to care management team
- Works with clients and outside agencies to help address client medical/social service needs as per care management plan
- Educates patients regarding how to navigate throughout the health system.
To perform the job successfully, an individual should demonstrate the following competencies and skill sets:
Skill Set; Communications
Oral Communication – The ability to express oneself clearly in conversations and interactions with others. Speaks clearly and can be easily understood. Organizes ideas clearly in oral speech. Expresses ideas concisely in oral speech. Summarizes or paraphrases his/her understanding of what others have said to verify understanding and prevent miscommunication.
Written Communication – The ability to express oneself clearly in business writing. Expresses ideas clearly and concisely in writing. Organizes written ideas clearly and signals the organization to the reader (e.g. through an introductory paragraph or through the use of headings). Writes using concrete, specific language. Spells correctly. Writes grammatically. Uses punctuation correctly.
Interpersonal Awareness – The ability to notice, interpret, and anticipate others’ concerns and feelings, and to communicate this awareness empathetically to others. Understands the interests and important concerns of others. Notices and accurately interprets what others are feeling, based on their choice of words, tone of voice, expressions, and other non-verbal behavior. Understands the unspoken meaning in a situation. Says or does things to address others’ concerns.
Customer Orientation – The ability to demonstrate concern for satisfying one’s external and/or internal customers. Quickly and effectively solves customer problems. Talks to customers to find out what they want and how satisfied they are with what they are getting. Lets customers know he/she is willing to work with them to meet their needs. Helpful, positive manner with peers, subordinates and customers.
Skill Set; Achieve Results
Technical Expertise – The ability to demonstrate depth of knowledge and skill in key work process areas. Is sought out as an expert to provide advice or solutions in his/her area. Is knowledgeable in the tools used to support key work processes. Can train and coach key work processes to staff in their area. Is aware and follows agency policy and procedures consistently.
Initiative – Identifying what needs to be done and doing it before being asked or before the situation requires it. Seeks out others involved in a situation to learn their perspective. Takes independent action to change the direction of events.
Results Orientation – The ability to focus on the desired results of one’s own work, setting challenging goals, focusing efforts on the goals, and meeting or exceeding them. Maintains commitment to goals in the face of obstacles and frustrations. Finds or creates ways to measure performance against goals. Has a strong sense of urgency about solving problems and getting work done.
Thoroughness – Ensuring that one’s own work and information are complete and accurate. Sets up procedures to ensure high quality of work (e.g. review meetings). Verifies information. Checks the accuracy of own work. Develops andPerforms all other duties as assigned by the Director of Care Coordination.
Education: LPN Graduate from an accredited school. Must have a current Connecticut State Licensure.
Experience: Minimum of one (1) year experience in a long-term care facility or rehabilitation center. Clinic experience is highly desirable.
Knowledge/Abilities: Excellent Patient Management skills. Must be strongly motivated and able to accept supervision. Computer skills are essential with the ability to learn AS400, SRS, MDLink and Mednexus. Ability to provide phone triage along with knowledge of referral process, medication refill procedures and Hollister charting are also required. Knowledge of CLIA waived lab testing, Urine Dipsticks and Gucometers are necessary. Excellent leadership qualities and knowledge of management skills are necessary. Bilingual individual is desirable.
Physical Demands/Working Conditions
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is occasionally required to stand or sit for extended periods of time. The employee must occasionally lift and/or move up to 40 pounds.
How to Apply
Cornell Scott – Hill Health Center