LPN Care Coordination Program - Full Time

Watson Clinic LLP; Lakeland (FL); On-site; USD 52,000 - 68,000; Full time

Job summary

Watson Clinic LLP in Lakeland, FL seeks an LPN Care Coordinator to manage patients with complex needs, focusing on transitions of care and chronic disease management. You will work with care teams to support efficient, high‑quality care in the community.

Requirements include graduation from an accredited LPN program, Florida licensure, 2 years' inpatient/ambulatory care experience, and Excel proficiency. The role involves care planning, patient education, and collaboration across care partners.

Qualifications

• Graduate of an accredited Licensed Practical Nurse program.
• Florida licensure required.
• Two years’ experience in inpatient and ambulatory care settings.
• Proficiency with Excel.
• Excellent listening and interpersonal skills.

Responsibilities

• Identify patients for inclusion in program using available metrics.
• Coordinate care, med reconciliation, and transitions of care post-discharge.
• Educate patients on disease management and self‑management.
• Maintain care plans and document encounters in the EHR.
• Perform home, hospital, and clinic visits as appropriate.
• Process billing transactions for Transition of Care Management.
• Utilize Microsoft Office Suite to manage data and reports.

Skills

LPN License

Communication

Problem Solving

Education

Licensed Practical Nurse (LPN)

Tools

Excel

Job description

Summary/Objective

Objective is to manage patients with complex needs to include: Transition of Care Management and Chronic disease management, active care planning and management of “high utilizers”, Medication Reconciliation and identifying barriers care to assist with successfully managing their disease state. The LPN Care Coordinator is an essential member of the Value Based Services team at Watson Clinic. He or she will work with both the care teams and the patients to support the goals of providing efficient, effective and quality care to our community.

Full-time Description

Summary/Objective

Objective is to manage patients with complex needs to include: Transition of Care Management and Chronic disease management, active care planning and management of “high utilizers", Medication Reconciliation and identifying barriers care to assist with successfully managing their disease state. The LPN Care Coordinator is an essential member of the Value Based Services team at Watson Clinic. He or she will work with both the care teams and the patients to support the goals of providing efficient, effective and quality care to our community.

Essential Functions

• Identify patients for inclusion in program utilizing available metrics.
• Identifies and reduces barriers to care utilizing health plan services, community resources and organization as appropriate.
• Perform comprehensive patient assessments upon entry to service and periodically to include an assessment of patient and family support system and needs.
• Contact patients telephonically for care coordination and medication reconciliation post-discharge for hospital and skilled nursing discharges.
• Assists patient in gaining access to PCP and specialist appointments as needed.
• Follow established protocols to educate patients on disease management and promote patient self‑management.
• Follow up on DME needs (met or unmet) and home health agency issues.
• Perform case reviews for ‘fragile few’ to present to treating physician.
• Develop and implement individualized patient care plan (that is goal driven) with a focus in disease management and patient empowerment.
• Assist patient and family with navigation of their health care plan.
• Monitor care plans and patient progress to goal achievement; revise plan as necessary providing education and support as appropriate.
• Assist patient and family to access available community resources as appropriate.
• Assists patient in gaining access to PCP and specialist appointments as needed.
• Maintain contact with patient and family through transitions of care while coordinating with other care team members.
• Participates as an active member of the patients care team collaborating with patient, family, providers, clinic staff, and other care partners.
• Document all encounters and patient related discussions, telephonic or in‑person, in the EHR.
• Conduct home, hospital and clinic visits as appropriate, following established guidelines, policies and procedures.
• Process billing transactions as appropriate for Transition of Care Management.
• Utilize Microsoft Product Suite, including but not limited to, insertion of data in an Excel spreadsheet from EHR. Use of Microsoft Word to create narrative reports of project(s) status.

Requirements

Graduate of an accredited Licensed Practical Nurse program. Florida licensure required. Two years’ experience working in both inpatient and ambulatory care setting (physician office setting, hospital or Hospice). Proficiency with Excel. Excellent listening and interpersonal skills. Ability to maintain confidences. Must be flexible, resourceful, and able to problem solve. Must be able to handle multiple tasks simultaneously and set Priorities

Preferred Education and Experience

Bachelor’s degree, Case Management Certification