Care Coordinator- LPN, Population Health, FT, Days

North Mississippi Medical Center   Tupelo, MS   Full-time
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Primary responsibility is to assist with coordination of healthcare services under the direction of the physician and/or clinical supervisor for specific insured populations within the North MS Medical Clinics, Inc. and surrounding area. The nurse will work with the Program Director and primary care provider to develop this position to best serve the needs of the patients.

Assists the patient care team in providing the highest quality of care on a population based level in a cost effective manner. Must demonstrate clinical expertise and must model the clinical practice standards in assigned patient populations including, but not limited to:

* Transition of care management: Coordinates continuity of care with patients and families after discharge from post-acute settings such as skilled nursing facilities, swing bed, rehabilitation services, hospitals, long term care facilities, and ER.
* Pre-Visit planning: Works with disease registry to identify and contact at risk patients with care gaps prior to or at their scheduled appointment.
* Chronic disease management: Uses risk stratification tools and predictive modeling to identify high risk patients for case management services.
* Patient engagement: Promotes wellness by empowering the patient to be proactive in his/her own healthcare.
* Wellness: Assesses payor benefits of patient populations and coordinates care to include follow up of recommended screening services based on age, gender, and conditions. Leads organizational strategies to promote prevention and wellness.
* Collaboration: Works with the patient care team to move populations through the continuum of care. This will include serving as a bridge with consulting physicians, hospitals, ER, insurance companies, other frequently used healthcare resources, and the patient and/or family
* Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
* Possesses clinical expertise in standards of clinic practice and nursing care. Keeps abreast of new evidence-based standards of health care.
* Coordinates and facilitates communication into the patient medical record regarding the patient to enhance the care of the patient such as obtaining specialist reports, hospital reports, labs, diagnostics, and so forth. It is an expectation that the care coordinator will collaborate with the health managers to ensure a cohesive approach to patient care.
* Develops systems for information collection and data mining. Actively works with Information Systems staff to integrate information technologies into daily practice operations.
* Acts as a disease registry expert, anticipates patient needs, and assists in identifying at risk/high risk populations through evidence based care.
* Participates and/or assists in data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Population Health Program. Uses an electronic medical record to organize clinical information and facilitate outcomes data collection and analysis. Interprets data on a routine basis and communicates with the care team and patients to improve patient outcomes.
* Collaborates with physicians, administration and all office personnel to develop and implement strategies to improve clinical outcomes.
* Utilizes analytical tools to provide outreach to patient populations for scheduling of wellness visits within NMMCI

Requirements:

* LPN with active MS Licensure, Minimum of five years clinical experience.
* Working knowledge of computer and software programs including data base management, Microsoft Word, Power Point and Excel programs, Electronic Medical Records and disease registry
* Must have skills necessary to make both visual and oral presentations to all levels of NMMCI and outside health care communities.

At North Mississippi Health Services, our mission is to "continuously improve the health of the people of our region." Our vision is to "provide the best patient and family-centered care and health services in America." We believe that fulfilling our mission and vision calls us to embrace the best people that form incredible connections to our patients and families.

We take pride in celebrating everything that makes you uniquely you - your talents, your perspectives, and your passions. At North Mississippi Health Services, we believe in connecting your passion with a purpose. When you are part of our team, you know what connected feels like.
This job is no longer available.

North Mississippi Medical Center

Tupelo, MS