Clinical Coordination & Support
4 days ago
New York
Job DescriptionBenefits: • 401(k), • Flexible schedule, • Health insurance, • Paid time off Patient Assessment and Coordination • Conduct initial and follow-up assessments focused on patients medical, psychological, and social support needs under the direction of the RN Care Manager., • Assist in developing and implementing individualized care plans in collaboration with the RN Care Manager and interdisciplinary team., • Monitor patient status through telephonic and in-person outreach to ensure continuity of care., • Support Care Management face-to-face assessments in the home, community, or clinical setting as directed by the care team.Patient and Family Education, • Provide patient-centered education on care plans, medications, chronic disease management, and preventive health practices., • Support families in understanding available health plan resources and empower them to make informed decisions about care., • Reinforce patient self-management goals identified by the care team.Care Transition Management, • Assist in care transition activities by coordinating follow-up appointments, medication reconciliation support, and patient/family education after discharge., • Communicate patient status and needs effectively to providers, RN Care Managers, and other team members to support safe transitions between settings (e.g., hospital, rehab, home).Resource Coordination, • Identify patients in need of social services or community-based resources and route referrals to the appropriate non-clinical coordinators or social workers., • Act as a liaison between patients, caregivers, and the healthcare team to promote access to needed medical and social supports., • Provide ongoing support to clinical staff by tracking progress toward care plan goals and reporting barriers or successes.Documentation and Reporting, • Maintain timely, accurate, and comprehensive documentation in the electronic health record (EHR) in accordance with organizational standards and regulatory requirements., • Prepare and maintain tracking logs for outreach, education, and follow-up activities., • Contribute to reporting on patient progress, barriers to care, and program outcomes.Clinical Risk Escalation, • Identify potential clinical concerns, deterioration in condition, or risk issues during patient outreach., • Promptly escalate concerns to the RN Care Manager or Supervisor for higher-level intervention., • Collaborate with the interdisciplinary team to address clinical issues and prevent avoidable adverse outcomes.Other Responsibilities, • Participate in mandatory in-person team/company meetings, ongoing training, and case reviews., • Provide updates on assigned patients at interdisciplinary team meetings., • Perform other duties as assigned in support of patient care and program objectives.Qualifications, • Current and valid LPN license in the state of practice., • Strong clinical knowledge of chronic disease management, preventive care, and medication adherence., • Prior experience in care management, managed care, community health, or ambulatory care preferred., • Excellent communication, interpersonal, and organizational skills., • Compassionate, patient-centered approach with the ability to build trusting relationships., • Proficiency in EHR systems and intermediate computer skills (Excel, Outlook, Teams, Word, etc.)., • Ability to manage multiple priorities, meet deadlines, and work both independently and as part of a multidisciplinary team., • Skilled in motivational interviewing and patient engagement strategies., • Demonstrated time management and critical thinking skills.Job Type: Full-time Pay: From $75,000.00 per year Benefits: • 401(k), • Health insurance, • Life insurance, • Paid time off, • Vision insuranceLanguage:, • Spanish (Required)License/Certification:, • LPN (Required)Work Location: Hybrid remote in Bronx, NY 10463 Flexible work from home options available.