Comprehensive Rehab Consultants (CRC) is building the future of nursing homes. We empower nursing home teams to provide exceptional clinical care to their elderly patients by embedding our clinicians and technology.As a CRC employee, your work will be on the cutting edge of post-acute care and you can expect to take on challenges never attempted before in our industry. Our culture is obsessed with problem-solving to better serve the geriatric population, and we make all of our decisions reflecting our mission to make a high standard of care accessible to everyone.We are looking for a Care Coordinator that will be responsible for delivering transitional care and chronic care management services. Our team achieves results by being innovative, driven, collaborative and trustworthy.While we've historically kept our team small, we simply can't ignore the opportunity ahead of us now. This is one of the most important roles we'll ever hire and will be responsible for executing against ambitious goals with significant autonomy and support.Benefits:Great health insurance including: Medical, Vision, and Dental | Short Term Disability, Life Insurance, Critical IllnessGenerous PTO package and time-off on selected holidaysHighly competitive salary and generous bonus401(k) plan with an annual contribution of 2-3%Role:The LPN Care Coordinator will be responsible for delivery of Transitional Care and Chronic Care Management services allowing patients to thrive and progress toward desired outcomes. Responsibilities include post-discharge patient outreach, patient-centered care plans, and service coordination utilizing software tools that facilitate communication and exchange of information with patients, CRC providers, and other care team members.ResponsibilitiesDetailed review of EMR record to inform initial outreach and care plan areas of focusPerform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriersCommunicate assessment findings, care plan goals, interventions and outcomes to provider, patients, and caregivers in a timely mannerMonitor patient’s ED visits and acute stays, perform post-discharge follow up calls and continuously assess risk of readmissions post-dischargeUtilize motivational interviewing to promote patient engagement and empower patient to develop self-management skillsProvide chronic disease education and symptom management teaching to patients and caregiversCommunicate proactively with provider to address patient change in status or obtain any necessary referrals/ordersDocument care plans, clinical interventions, and outreach in care management software systemDevelop and maintain effective professional working relationships with assigned providers and other care management team membersEducation and Experience:High school diploma or equivalent required. Associates or Bachelors preferredLicensed LPN/LVN or Registered NurseA minimum of two (2) years of care coordination experience including post-discharge transitions of care requiredExperience providing care coordination to a skilled nursing and/or Medicare beneficiary population requiredExperience with SNF to home transitions of care or SNF bundled payment care coordination highly preferredCompetencies, Knowledge and Skills:Knowledge and experience with electronic medical record (EMR) and Care Management technologyDisplay a strong customer service, patient-focused orientationAbility to be flexible in an ambiguous and dynamic environmentStrong collaboration and conflict resolution skill setsStrong decision making and problem-solving skillsEffectively engages diverse populations and provide culturally sensitive coaching, education, and assistanceAbility to develop, prioritize and accomplish goals/time management
about 1 month ago