Senior Nurse Care Coordinator - Value-Based Care & Transitions

CHRISTUS Health; Irving (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

CHRISTUS Health is seeking an LVN/LPN Care Coordinator to manage patient care coordination within our value-based network. You will support CMS/ACOs programs, mentor care coordinators, and ensure adherence to quality metrics.

The role emphasizes leadership, regulatory compliance, and cross-functional collaboration to improve preventive care and patient outcomes across CHRISTUS Health ministries.

Qualifications

• LVN/LPN license in the state of employment.
• Minimum 3 years clinical or home health experience.
• 5 years supporting value-based care programs, accountable care organizations, or HEDIS.
• Knowledge of CMS/ACO/HEDIS and payor cost sharing preferred.
• Experience with physician practice operations.

Responsibilities

• Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices.
• Monitor regulatory requirements, organizational policies, standing delegated orders and protocols.
• Identify quality gaps and risk adjustment gaps; participate in Quality Improvement Programs.
• Assist in developing tools, education, and workflow processes for CMS/ACO/payor quality initiatives.
• Conduct internal review audits to improve documentation and efficiency of the care coordination team.
• Support Primary Care Providers and schedule preventive screenings and appointments; maintain communication with providers.
• Pull reports to monitor care gaps and conduct telephonic outreach for care gap closure and medication adherence.
• Provide counseling and health education to patients and families using standardized protocols.
• Escalate health concerns to PCPs and place referrals to care team members; coordinate follow-ups.
• Communicate resources and services available across the continuum of care.
• Document data using standard assessment tools and maintain chart compliance.

Skills

Leadership

Communication

Care coordination

Regulatory knowledge

Mentoring

Outreach

Epic EHR

Education

LVN/LPN license

High School Diploma

Tools

Epic

Job description

CHRISTUS Health is seeking an LVN/LPN Care Coordinator to manage patient care coordination within our value-based network. You will support CMS/ACOs programs, mentor care coordinators, and ensure adherence to quality metrics.

The role emphasizes leadership, regulatory compliance, and cross-functional collaboration to improve preventive care and patient outcomes across CHRISTUS Health ministries.