LPN Care Coordinator: Chronic & Transitional Care

Robert-C.-Byrd-Clinic-1; Lewisburg (WV); On-site; USD 30,000 - 44,000; Full time

Job summary

WVSOM Health on the campus of the West Virginia School of Osteopathic Medicine in Lewisburg, WV, is expanding our care coordination team and seeking a full‑time LPN Care Coordinator.

You will support physicians, mid-level providers, and nurses, handling patient inquiries, triage, and essential CCM, TCM, and RPM activities in-person and through the telephone and EHR portal communications.

Qualifications

• Strong communication and customer service skills are essential.
• Thorough knowledge of disease processes to ensure appropriate triage and care for patients.
• Comprehensive understanding of healthcare practices and protocols.
• Excellent computer skills, preferably with experience using electronic health record (EHR) platforms.
• Knowledge of CMS guidelines and documentation requirements for CCM, TCM, and RPM preferred.
• Experience with care coordination, chronic disease management, population health, or value-based care preferred.

Responsibilities

• Provide direct care to patients as assigned and qualified to perform while under the direction of a nurse, physician orders, or established protocols.
• Answer phones courteously, assisting patients with healthcare inquiries, and handling upset patients with de-escalation techniques.
• Document all phone interactions, including attempted calls, in patient charts.
• Conduct phone interviews to gather necessary information for providers.
• Schedule patient appointments promptly and return calls by the end of the day.
• Welcome patients warmly, addressing concerns and easing anxiety.
• Triage patients based on care urgency and clinic protocols.
• Record vital signs accurately and update patient histories.
• Conduct initial patient assessments and participate in patient education.
• Maintain accurate patient records and complete charting promptly.
• Process stat referrals efficiently.
• Assist with CCM programs including monthly outreach, care plan development and updates, medication reconciliation, goal setting, and documentation.
• Assist in TCM activities including post-discharge outreach and coordination of follow-ups.
• Assist RPM programs by reviewing transmitted data, noting abnormalities, and educating patients.

Skills

Communication skills

Disease knowledge

Computer skills

CMS guidelines knowledge

Care coordination

Tools

EHR systems

Job description

WVSOM Health on the campus of the West Virginia School of Osteopathic Medicine in Lewisburg, WV, is expanding our care coordination team and seeking a full‑time LPN Care Coordinator.

You will support physicians, mid-level providers, and nurses, handling patient inquiries, triage, and essential CCM, TCM, and RPM activities in-person and through the telephone and EHR portal communications.