LPN Care Manager (Hybrid Remote) (Clay, Coosa, ...

This position is hybrid-remote and will require occasional work shifts in the office setting.The Care Coordinator is responsible for ensuring linkages for CCBHC patients and the community to provide seamless transitions across the health services spectrum. This includes physical and behavioral health, community services (i.e., social services, housing, educational systems, employment services, and other needed services) as needed to facilitate wellness and recovery of the whole person, based on a person-centered plan of care, as required by CCBHC. The Care Coordinator will work collaboratively with clinical and non-clinical staff, external providers, and community resources to assist clients in overcoming barriers to care, improving health outcomes, and promoting overall well-being. The Care Coordinator must be patient-focused, detail oriented, well organized, and proficient in management of patient electronic health records. The role requires strong communication and problem-solving skills.General Responsibilities:Assess and re-evaluate patient needs utilizing information from EHR and additional tools as appropriate to determine patient needs and preferences and communicate those to all treatment participantsCreate an Integrated Care Plan in conjunction with the patient and/or caregiverEnsure the patient understands the Care Plan and is equipped to follow itIdentify and address all barriers that might impede the ability of the patient to care for themselvesAssemble appropriate team of professionals to assist in meeting patient needs, organize patient care activities and share information among all participantsAssist the patient/caretaker in navigating the health system while addressing any insurance coverage issuesUpdate assessment and care plan at least every 90 daysUtilize the Integrated Care Plan to drive all activities and servicesProvide information and feedback in daily Huddles regarding needs, plans/interventions/resultsResearch ways to meet needs and put action steps in place, monitor for progressAdvocate on behalf of the patientFollow up regularly with patient to ensure needs are being met and identify any changes to patient circumstances, any compliance concernsConsult with treatment team when noncompliance is foundProvide training on disease management and healthy living skillsProvides initial Diabetes Care IntroductionProvide support and education for patient and their support systemFacilitate securing/providing medical records when patient is in the hospital, ED, etc.Track and support patients when they obtain services outside the practice.Follow-up with patients within a few days of an emergency room visit or hospital discharge.Communicate test results and care plans to patients/families.Collaborate and consult with staff members and outside sources in the delivery and arrangement of servicesDemonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situationEffectively demonstrates the application of adult specific competenciesSupervision and Consultation:Seek supervision and consultation as neededAccept and employs suggestions for improvementActively works to enhance skillsClinical Record Keeping:Document in a timely fashion per AltaPointe policyDocument in a clear and concise manner.Document legiblyCourteous and respectful attitudes towards consumers, visitors, and co-workers:Treat patients with care, dignity, and respectRespect privacy and confidentialityAssist others as neededAdopt a teamwork approach with coworkersAdministrative and Other Related Duties as Assigned:Actively participates in Performance Improvement activitiesActively participates in AltaPointe committees as requiredCompletes assigned tasks in a timely mannerFollows AltaPointe policies and proceduresAttends appropriate in-services training and other workshopsAlabama Licensed Practical Nurse (LPN) in good standing, three years’ experience in nursing is required. Experience working with and accessing community resources; Proficiency in accurate and timely documentation of care coordination in the electronic health record; Demonstrated ability to work with multi-disciplinary teams; Prior work with the special populations as required by CCBHC, preferred. Proficiency in managing multiple priorities.

Created: 2025-10-04