Care Coordinator

Bridges Health is looking for a self-motivated, productive LPN to become our new Care Coordinator. The Bundle Payment for Care Improvement (BPCI) Care Coordinator is responsible for chronic disease management, telephonic communication with patients and medication Reconciliation. This position will be stationed at our central intake office in Oklahoma City, and will work with all of our facilities in Oklahoma and their care teams.
Responsibilities and Purpose

• Identify the BPCI-A patient and track the transition.
• Establish an expected LOS to diagnosis based upon the care pathway.
• Validate post-acute facility placement.
• Help inform the team to implicitly round on patients routinely to validate the care plan and pathway success.
• Assist/support medical issues within the changing continuum.
• Maintain high quality post-acute effectiveness, efficiency and quality.
• Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns.
• Track and support patients when they obtain services outside the practice such as Emergency Departments, Hospitals and other health care facilities.
• Follow-up with patients within a few days of an emergency room visit or hospital discharge.
• Working collaboratively with other team members, provide care management services for high risk patients.
• Provide relevant self-management support for patients with chronic illnesses as identified by clinical teams.
• Manage referrals, when needed, to appropriate agencies required to assist the client in achieving the goals and objectives identified in their care plan.
• Work with patients both in person and over the phone to remind and review their plan of care and progress towards their goals.
• Act as a liaison between the Intake Team and the facility.
• Assist with data collection and generation of patient registry reports.
• Create reports based on customer surveys and admission data.

Desired Skills and Experience

• Current and unencumbered Licensed Practical Nurse (LPN) License preferred.
• Strong written and verbal communication skills.
• Medication Reconciliation.
• Proven data analysis skills.
• Resourcefulness in problem solving.
• Proven organizational skills.

Benefits
We offer competitive pay relative to experience. All full-time employees are eligible for benefits including:

• Medical, Dental and Vision Insurance
• 401(k) with Company Match
• Employee Assistance Program
• Wage Advances via OnShift Wallet
• Education Funds and Scholarships
• Nurse Aide Training and Certification
• Career Ladders- CNA, RN, and Beyond
• Clinical Hours For College Students
• CPR and IV Certifications
• Employee Stock Ownership Plan (ESOP)

Earn Better With Us | Realize the Value of 100% Employee Ownership
We are 100% employee-owned by members of the community we serve through an Employee Stock Ownership Plan (ESOP). We can impact the total value of your compensation in 4 significant ways:

1. We pay future employee-owners competitive wages based on their experience and provide pathways for career advancement.
2. We allow you to access up to 50% of your net earned wages the following day when you need cash immediately.
3. We offer an 401(k) with matching so that you can begin wealth-building today
4. More remarkably, we create a future reward for every eligible team member at no cost so you can live comfortably when your working days are over.

Ownership inspires a rich culture of teamwork where your attention to detail, customer service mindset, pride, effort, and attitude contribute to a vision of superior satisfaction and quality outcomes for everyone entrusted to our care.
We are an Equal Opportunity Employer.
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