Post Acute Manager, Complex Care; LPN

Position: Post Acute Manager, Complex Care (LPN)

We’re unique. You should be, too.

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

* This position is mostly a remote role, with the occasional requirement to go on-site or in-home with patients (roughly 10%).
The Post Acute Manager, Complex Care (LPN) is a Licensed Practical Nurse (LPN) who work with our patients post discharge with high needs in close collaboration with other members of the Complex Care team, center teams, and their primary care physicians, to meet their immediate medical and social needs with the aims of fully re-engaging them in our intensive primary care model and maximizing their healthy time at home from the day they are post discharge from a hospital until they see their PCP for the first time as a follow up.

The success of this role is determined by the number of hospital arrivals that engaged patients have from the day of hospital discharge until the day of PCP post discharge follow up.
The Post Acute Manager, Complex Care (LPN) is a vital Post Acute Team member who focuses on medical stabilization of our post hospitalized patients by engaging them in their post-acute facilities, telephonically, during center visits and telephonic outreach. The incumbent will address immediate patient needs that may cause readmissions, re-engage patients back into PCP care, and reinforce discharge plan through education and care coordination.

The incumbent establishes strong relationships with their patients, patients’ family members and caregivers, and other team members to achieve meet post discharge needs and ensure the patient returns to PCP care without need for readmission.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Under the direction and supervision of a Registered Nurse (RN) provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital.
• While conducting a home visit or a center visit with our patient compiles patient health information, takes and records vital statistics, takes blood pressure and conducts other basic care treatments. Records patients' medical history and other information such as test results in the medical record.
• Performs 4-day discharge phone call on patients discharged from a hospital, SNF, LTAC within 24-48 hours of discharge.
• With a physician order draws blood (phlebotomy) and collects other lab specimens.
• Using the medication list provided in our DASH system and approved by the physician to fill pill boxes for patients.
• Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
• Assists patient and family with completion of Medicaid application for support and access to community/financial resources and refer cases to social worker as appropriate.
• Assesses the environment of care, e.g., safety and security, using our home safety evaluation form.
• Provides education with patient/family on different health concerns using standardize education directed by the Registered Nurse (RN).
• Coordinates the delivery of services to effectively address patient needs.
• Visits patient at home under the direction of the patient’s primary care physician to meet urgent patient needed.
• Performs other duties as assigned and modified at manager’s discretion.

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of medical products, terminology, services, standards, policies, and procedures

• Ability to effectively collaborate with team members, including physicians, HCT team members such as Manager of Community, Registered Nurse (RN), Community Health Worker (CHW) market leaders, center managers and front desk team staff

• Ability to exercise patience, compassion and empathy for patients and family members

• Ability to act calmly in busy or stressful situations.…