LPN Nursing Home Care Coordinator

COMMUNITY HEALTH:

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties.

ABOUT THE ROLE:

In this office-based role, the Community Health LPN Nursing Home Care Coordinator blends administrative care coordination with a clinical nursing foundation to ensure high-quality, efficient, and patient-centered care for Community Health patients residing in nursing facilities(SNF). The Care Coordinator supports the provider team, facilitates transitions of care, maintains accurate medical records, and ensures compliance with regulatory and organizational protocols.

This is a fast-paced, dynamic role suited for a licensed LPN with a passion for geriatric care, strong organization and communication skills, and comfort navigating electronic health records (EHRs).

Community Health's Skilled Nursing Facility(SNF) service line provides on-site, embedded medical care and care coordination for patients residing in Mountain View Center, Rutland Center for Living & Rehabilitation, and The Pines. The LPN Geriatric Care Coordinator serves as a key connector between Community Health embedded skilled nursing facility providers, skilled nursing facility (SNF) staff, and patients.

FUNCTIONS OF THE POSITION:

• Serve as the central communication point between Community Health embedded skilled nursing facility providers, and SNF nursing teams.
• Maintains detailed, accurate and timely documentation in the EMR related to patient care and patient demographics
• Monitors the facility patient census, status changes (e.g., admissions, discharges, regulatory visits, room transfers) and prepares the daily patient encounter list for providers
• Performs medication reconciliation, maintaining an accurate medication list in EMR. Updating, changing, or reordering medications per the instruction of the provider.
• Communicate accurately and clearly any patient medication changes made by the provider to the SNF Nursing Staff
• Facilitates the coordination of patient lab orders, imaging studies, referrals and externally specialty provider appointments
• Tracks lab orders, imaging studies, referrals to completion ensuring results are received back into the EMR for the provider to review.
• Coordinate and schedule all necessary regulatory visits for patients with providers, ensuring compliance with all state and federal regulations, according to the Centers for Medicare and Medicaid Services (CMS).
• Strong Triage skills to manage incoming calls from SNF staff, triaging needs and escalating as appropriate.
• Participate in discharge planning and complete transition templates for handoff to Primary Care Care Managers to ensure safe transition out of the facility
• Build strong relationships with SNF staff and act as a professional representative of Community Health.
• Participate in team huddles, quality improvement initiatives, and care planning meetings.
• Cross coverage of other locations and service lines for continued support and access for patients
• Perform minimal hands-on clinical skills such as EKGs and Vital Signs as needed
• Foster a culture of respect, accountability, and excellence in care delivery.

SKILLS REQUIRED FOR SUCCESS:

• Current Vermont LPN license (or can obtain upon offer of employment)
• Prior experience working in a nursing home/ geriatrics preferred.
• Excellent written and verbal communication skills for interacting with multiple stakeholders
• Able to manage multiple tasks, prioritize responsibilities, and maintain accurate documentation.
• Experience in using a variety of electronic medical records and ability to learn other systems
• Strong interpersonal skills and ability to work independently

HOW WE SUPPORT YOU:

• Work Life Balance
• Monday- Friday work schedule. No evenings, weekends, or Holidays
• Opportunities for career growth in geriatric care and care management
• Generous Time Off
• Medical, dental, and vision insurance.
• Health savings account option.
• Robust 403 (b) retirement savings plan, with employer match and 100% vesting schedule.
• Comprehensive Wellness Program