High Risk Care Coordinator
New
O
Oasis Health PartnersPrimary Care
This role is open to applicants currently residing in the United States.Full-TimeMiddle
Salary33.65 - 48.08 USD per hour
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Job Details
- Experience
- At least two years of prior nursing experience in care coordination, population health, or chronic disease support
- Required Skills
- EHR
Requirements
- Completed an accredited practical nursing (LPN) program.
- At least two years of prior nursing experience in care coordination, population health, or chronic disease support.
- Licensed as a Licensed Practical Nurse (LPN) and credentialed in good standing in the applicable state(s) of practice.
- Experience making structured, outbound calls, preferably in a call-center environment.
- Experience supporting high-risk patients with chronic conditions, care management, or utilization reduction.
- Comfortable performing medication reconciliation, structured symptom monitoring, and care coordination.
- Strong patient communication skills, including the ability to engage, motivate, and support patients.
- Proficient in EHR documentation and care management or population health tracking tools.
- Highly organized, dependable, and emotionally intelligent.
- Able to multitask effectively in a fast-paced outreach environment.
Responsibilities
- Conduct regularly scheduled outbound outreach to high-risk patients to support ongoing care management, reduce avoidable utilization, and address gaps in care.
- Contribute to the development of a new high-risk patient management program by helping design, test, and refine outreach workflows, documentation practices, and care coordination processes.
- Perform medication reconciliation and adherence support by reviewing patient-reported medication use, identifying discrepancies, and escalating concerns to the RN or Provider.
- Collect, assess, and document patient-reported symptoms, condition trends, risk indicators, and barriers to adherence within LPN scope of practice.
- Provide disease-specific education, self-management reinforcement, and motivational coaching.
- Coordinate home health services and durable medical equipment (DME) needs under RN or Provider direction.
- Identify and address social determinants of health impacting high-risk patients.
- Support coordination and monitoring for patients with complex chronic conditions, including COPD, CHF, diabetes, and hypertension.
- Serve as a consistent point-of-contact for assigned high-risk patient panels.
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