LPN Transitions Care Navigator

Overview

Great Lakes Integrated Network IPA (GLIN IPA), is seeking an energetic and self-motivated LPN Transitions Care Navigator to join our care management team on a full-time basis.

GLIN IPA, an affiliate of Kaleida Health and Erie County Medical Center Corporation, is a Buffalo-based, physician-led independent physicians association (IPA) consisting of approximately 1,000 physicians in primary and specialty care. The mission of GLIN IPA is to transform the healthcare experience in Western New York (WNY), promoting high-quality, equitable, and efficient healthcare through innovation and collaboration. With a focus on the premier network of providers in WNY, GLIN IPA’s vision is to drive better health and experiences for all patients.

We offer an outstanding benefits package including health, dental, 401K, vacation, and PTO, as well as a great working environment

The LPN Clinical Care Navigator works with patients to help them find solutions to their healthcare scheduling needs and help to manage chronic illnesses by assisting the patient in their navigation of the healthcare system to access the providers and resources they need. This position also facilitates gap in care closure to support our success in various quality programs as well as improving patient outcomes.

• Provide Education and Resources relative to the patient’s diagnosis and treatment plan
• Educate on disease process, goal setting and will monitor patients identified for wellness, transitions care, chronic care and high risk care management programs
• Provide teaching to patients/families related to patient’s diagnosis, pathology, medical and nursing treatment plans, discharge needs and health goals
• Identify possible problems that could lead to an emergency/crisis situation and takes appropriate action to de-escalate the potential for the situation to occur
• Identifying, facilitating and securing access to needed healthcare, social services benefits and community resources
• Using decision support tools and supervisory support to identify appropriate interventions and health care and social service needs
• Communicating with clients, their families and caregivers to support care plan goals and integrate care delivery
• Facilitating follow-up care after hospitalization or emergency room visit
• Track aftercare outpatient appointments following inpatient or acute levels of care
• Regularly coordinating and communicating with Care Team members on all care plan activities, including referrals, transition care planning, and follow-up tracking
• Working in collaboration with other care team members and care providers, including behavioral health, disease care management, home care, social work and community-based organizations, to help client achieve optimal health outcomes
• Collaborate with the payer systems and payer Care Coordinators on specific patient care needs
• Outreach to patients to ensure their compliance with treatment plans
• Meet with the team regularly to discuss improvement of outcomes and adjusting to the population’s need
• Maintains logs and other data bases regarding care coordination activities

Education and Experience:

• Licensed Practical Nurse (LPN) certification required
• At least 2 years’ experience in a healthcare setting, primary care experience preferred

Specialized Knowledge & Skills Needed for Performance of Job:

• Medically-based clerical experience
• EMR/EHR (Cerner/Power Chart/Medent/Health
  
  ENet/Health
  
  ELink)
• Microsoft Office (Excel/Outlook/Word)
• Ability for Collaboration with Team
• Some Medical Terminology Preferred
• Excellent customer service skills-ability to understand/exceed customer expectations while demonstrating the highest standards of care, respect, & confidentiality
• Must be able to work independently/alone and demonstrate self-motivation
• Comfortable with regular patient interactions and discussions centered around medical practice education
• Knowledgeable on how to navigate all aspects of medical care and managed care system
• Excellent communication skills both verbal and written
• Ability to handle multiple task and priorities
• Exceptional organizational skills

This is a hybrid position and candidates must reside in WNY to be…