Clinical Care Coordinator, LVN

Engage recently hospitalized patients to ensure appropriate follow-up medical care and services are provided. Evaluate patients for referral to care management, coaching, or resources to support self-management plans. Collaborate with physicians, medical assistants, and care managers to address patient needs timely per policy. Manage designated aspects of care including referrals, hospitalizations, ER visits, and ancillary testing. Provide telephone advice per protocol, handle urgent calls, and refer to physicians or case managers when appropriate. Anticipate patient needs to ensure documentation and referral authorizations are completed. Assess barriers to treatment goals and maintain accurate documentation of all care management activities. Participate in measuring clinical outcomes, quality improvement, and integrated population management initiatives.