Provide a monthly care management conversation through outbound phone calls to assigned patients to address their healthcare needs.
Communicate resources and services available to patients through the continuum of care.
Identify patient-specific problems, goals, and interventions designed to meet the patient’s individual needs through action-oriented and time-specific goals.
Maintain chart compliance and proper documentation, including but not limited to medical history, medication, immunizations, allergies, surgical history, and family history.
Demonstrate awareness of a patient’s circumstances that may necessitate revisions to care plans, goals, and preferences while being aware of barriers to care and services.
Provide appropriate health education.
Escalate patient concerns to the triage nurse team.

Bilingual LPN, Personal Care Coordinator I – Spanish

Key skills