SENTARA LPN CARE COORDINATOR (3654)

CVHS HEALTH SERVICES; Petersburg (VA); On-site; USD 31,064 - 39,495; Full time

Job summary

CVHS Health Services seeks a registered nurse with clinical office experience to coordinate patient care across multiple settings. The role involves educating patients about conditions, medications, and self-management, while navigating care pathways and ensuring accurate documentation in the EHR.

You will identify high-risk patients, coordinate with insurance plans, and perform outreach via secure channels. A hybrid work model includes mobile unit coverage 2–3 days weekly.

Qualifications

• Graduate of accredited school of nursing with RN license.
• Data entry, retrieval and report generation experience.
• 3 years in office clinical experience.

Responsibilities

• Coordinate patient care across the healthcare system and educate patients on conditions and medications.
• Identify high-risk patients and coordinate with insurance plans and health records.
• Perform outreach via secure email or phone to engage patients.
• Act as patient advocate and navigator through care transitions.
• Document each patient encounter in the electronic health record.
• Support hybrid work schedule and mobile health unit coverage as needed.

Skills

Patient care coordination

Communication

Confidentiality

Initiative

Judgment

Advocacy

Education

RN license (VA or compact state)

Job description

Job Details

Job Location: Petersburg, VA 23805. Position Type: Full Time. Salary Range: $22.55 - $28.67 Hourly.

ESSENTIAL JOB FUNCTIONS

• Patient care coordinators are liaisons between patients and the healthcare system. As a patient care coordinator, you would ensure that patients receive the care they need and that they understand their medical condition, medications, and other instructions.
• Identify high‑risk individuals by working with and while supporting Sentra’s insurance plan and via CVHS electronic record/practice management information.
• Perform regular outreach based on the patient’s personal preference, which could include email (if secure) or phone calls.
• Assist Sentara’s identified cohorts of patients through the healthcare system by acting as a patient advocate and navigator.
• Work closely with the Case Manager, Patient Educator, and others who assess the patient, to coordinate patient’s care and establish a plan of care.
• Support patient self‑management of disease and behavior modification interventions.
• Coordinate continuity of patient care with external healthcare organizations and facilities, by assuring all patient records are submitted to the Primary Care Provider.
• Help to manage high‑risk patient care, including patients with co‑morbidities or high risk for readmission to a hospital setting, including a registry.
• Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Participate on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient‑Centered‑Medical Home model.
• Customize care plans to meet the individual patient’s needs, prioritizing goals for patient’s health status; establish timeframes for re‑evaluation; identify resources to be utilized, including the appropriate level of care; plan for continuity of care, including transition of care; identify collaborative approaches to be used, including family participation.
• Work with the patient, their family and/or caregivers to identify self‑management support.
• Effectively research and resolve prescription processing rejections to ensure patients receive medications within established patient service standards.
• Work closely with other pharmacy teammates to ensure all orders are received and processed timely and accurately.
• Receive calls from patients and answer questions regarding prescription status, reimbursement, co‑payment assistance, health plan drug coverage, and other related questions.
• Maintain patient database information including personal, physician, prescription, insurance, agency, financial assistance and related data.
• Work in a hybrid capacity with scheduled coverage at the mobile health unit 2–3 days per week.
• Participate in Quality Assessment.
• Participate in Clinical Collaboratives.
• Document each patient encounter in the electronic health record.
• Support a team‑based approach to patient‑centered medical care.
• Attend work as scheduled.
• Managers may modify, add or remove essential job functions as necessary, or as changing organizational needs require.
• Complete annual competencies for current position, basic hands‑on nursing skills for patient care.
• Attend annual skills day offered for nursing staff.
• Assist with patient care within the site in the event of a catastrophic nursing shortage and when all other resources have been utilized.
• Perform other duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrate competence in performing essential duties.
• Ability to plan.
• Concern for patient confidentiality.
• Show initiative and use sound judgment in the absence of specific orders.
• Be resourceful.
• Act as a patient advocate.

EDUCATION, TRAINING AND EXPERIENCE

• Graduate of accredited school of nursing, licensed by the Virginia State Board of Nursing, or from a compact state.
• Data entry, retrieval and report generation experience.
• Required: 3 years in office clinical experience.