Care Coordinator, LPN
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Job Description
LPN coordinating remote kidney-care outreach, assessments, and documentation for Evergreen Nephrology’s value-based care programs. Supporting patients, providers, and care teams through chronic kidney disease management.
Responsibilities:
- Conduct monthly CCM touchpoints for assigned patient panels
- Build ongoing relationships with patients and caregivers through regular outreach
- Review patient chart data before calls, including diagnoses, kidney disease history, medications, labs, imaging, and treatment cycles
- Explain CCM participation and reinforce program benefits
- Conduct structured symptom assessments and evaluate changes using licensed clinical judgment
- Assess medication adherence issues, side effects, or regimen confusion
- Identify clinical red flags and escalate urgent issues according to triage pathways
- Collaborate with provider teams regarding symptom changes, concerns, and medication issues
- Route EHR messages with clinically relevant documentation
- Coordinate follow-up scheduling, labs, nephrology appointments, and efforts to reduce missed care
- Reinforce CKD and chronic disease care plans
- Explain symptom management instructions within LPN scope
- Support medication, lifestyle, and follow-up adherence
- Identify social, behavioral, or access barriers and determine appropriate interventions or referrals
- Document patient interactions in the EHR and CCM management platform
- Track qualifying CCM time for billing compliance
- Ensure documentation meets regulatory, internal QA, and partner expectations
- Maintain call quality and adherence to scripts and workflow pathways
- Maintain or exceed 80% monthly engagement, 90% billable conversion, and high QA/documentation accuracy scores
- Participate in peer reviews, QA audits, coaching, and continuing education
- Communicate recurring patient needs and trends to the Program Manager
- Perform other duties consistent with the role as assigned
Requirements:
- Active LPN or Licensed Vocational Nurse (LVN) license
- Bilingual (Spanish/English)
- Minimum 1–2 years of clinical experience in ambulatory care, population health, care coordination, or case management
- Strong clinical assessment, communication, and documentation skills
- Comfortable working in two systems (EHR + CCM platform) simultaneously
- Ability to manage a structured, metric-driven workflow with reliability
- Intermediate skills with MS Office Suite, including Outlook and Teams
- Home internet supporting at least 25 Mbps download and 10 Mbps upload
- Cable, Fiber, or DSL connections hardwired to the internet device are recommended
- Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information
- Experience in chronic disease management, virtual care, remote nursing, telehealth programs, CCM regulatory requirements, patient education, and motivational interviewing are preferred
Benefits:
- Paid time off starting at 4 weeks for full-time employees
- 12 paid holidays per year
- Medical, dental, vision and life insurance, including an HSA with employer match
- Reimbursement for continuing medical education for eligible roles
- 401(k) program with Evergreen matching up to 4% of contributions after six months of tenure
- Paid parental leave
- Robust training and development program beginning with onboarding and continuing throughout your career
- Quarterly bonus eligibility
- Evergreen provides remote employees with telephony applications and equipment to meet business requirements
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