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Posted 1 weeks agoLPN Care Coordinator, Embedded (Prince Georges County, MD)
at Ennoble Care
Prince Georges County, United StatesOn-site
Responsibilities
- Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR
- Facilitate transitional care management, ensuring services with the Housecalls division are initiated immediately upon a patient's discharge from the hospital
- Expedite time to first provider visit for newly transitioned patients in accordance with established guidelines
- Monitor patients attentively, communicate changes in condition promptly to the provider, initiate appropriate interventions, and escalate care as clinically indicated, including CCM-billable activities
- Collaborate daily with providers and facility staff to ensure care plans are kept current and acted on
- Maintain a consistent and reliable daily on-site presence in assigned facilities
- Build ongoing relationships with residents and their families, maintaining a consistent presence that reinforces trust and continuity of care over time
- Conduct routine and urgent vital sign collection as needed
- Perform regular patient check-ins to support care plans, follow-ups, and clinical stability
- Identify changes in patient condition and promptly communicate concerns to the clinical team
- Collaborate closely with Ennoble Care providers within the skilled nursing or long-term care setting
- Perform chart reconciliation to ensure accuracy and continuity of clinical records between Ennoble and facility records
- Support onboarding and training of new Embedded Care Coordinators
- Promote best practices in transitional care, communication, and facility-based care coordination
Requirements
- experience in a long-term care, skilled nursing or transitional care setting
- Solid working knowledge of healthcare terminology and care coordination principles
- Strong clinical assessment skills with the ability to identify and escalate changes in condition •
- Experience with EMR systems and clinical documentation; Point Click Care experience preferred
- Proficient with Microsoft 365 including Excel, Outlook, Word, and Teams
- Capacity to work independently while collaborating closely with multidisciplinary teams