Patient Care Coordinator - LPN

Patient Care Coordinator (LPN)

POSITION SUMMARY

Little River Medical Center is hiring a full-time Patient Care Coordinator (PCC) to support key programs including Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Annual Wellness Visits (AWV), Transitional Care Management (TCM), and Telehealth. This role is essential in ensuring patients receive timely, high-quality care through coordinated services, patient outreach, chart reviews, and accurate documentation in the electronic health record (EHR). The PCC serves as a bridge between patients, providers, and care teams, helping manage scheduling, follow-ups, patient education, and onboarding into care programs.

WHY LRMC:

Little River Medical Center is a non-profit community health center within Horry County. At Little River Medical Center, we strive to offer exceptional health services and deliver quality, compassionate care to everyone. We provide a wide range of affordable health and support services for every family. Our mission is to change lives and serve our communities.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Coordinate and oversee patient care services to ensure timely and high-quality support across multiple programs.
• Facilitate communication between patients, providers, and healthcare teams to ensure care continuity and adherence to program protocols.
• Maintain accurate and timely documentation of patient interactions, assessments, interventions in the electronic health record (EHR).
• Assist with scheduling and follow-up tasks to ensure patients receive necessary appointments and services.
• Monitor patient progress, track programs metrics, and escalate concerns to the appropriate team members.
• Ensure compliance with program guidelines, Medicare regulations, and organizational policies.
• Educate patients on preventative care, chronic disease management, and self-care strategies.
• Utilize technology and digital tools to support remote monitoring, virtual visits, and patient engagement.
• Collaborate with internal departments and external partners to improve workflows, optimize care coordination, and enhance patient outcomes.
• Participates in ongoing electronic medical record (EMR) training and assists the Health Information Systems Coordinator in optimized development and use of the EMR system with respect to self-monitoring patient care programs.
• Maintains excellent customer service relationships with patients, colleagues and outside partners.
• Adhere to clinical policies, protocols, standing orders, and best practice clinical care guidelines.
• Represents Little River Medical Center, professionally in all work-related interactions with vendors, community members and health care colleagues.
• Performs all other duties as assigned.

Program Specific Responsibilities:

• Remote Patient Monitoring (RPM)

• Monitoring patient vitals and biometric data through remote devices.

• Identify abnormal reading and escalate concerns to healthcare providers

• Educate patients on proper use of remote monitoring equipment.

• Provide patient education on using monitoring devices and managing chronic conditions.

• Conduct routine virtual check-ins to discuss patient progress, adherence, and any concerns.

• Document patient interactions, interventions, and escalations in the electronic health record (EHR).

• Collaborate with physicians, care coordinators, and other healthcare professionals to optimize patient care plans.

• Ensure compliance with HIPAA and other healthcare regulations related to remote patient monitoring.

• Assist with onboarding new patients into the RPM program, including device setup and troubleshooting.

• Participate in quality improvement initiatives to enhance the effectiveness of the RPM program.

• Chronic Care Management (CCM)

• Coordinate care for patients with chronic conditions, ensure they receive timely services and follow up care as outlined in their care plan. This includes reviewing patient records, medications, referrals, and ensuring the completion of required interventions.

• Maintain regular contact with assigned patients via phone calls, emails, or virtual platforms to provide education, support, and motivation for managing chronic conditions. Encourage patient adherence to care plans and identify potential barriers to compliance.

• Perform detailed chart reviews to assess patients' current health status, monitor progress, document interventions, patient interactions, and any significant changes in condition. Ensure accurate and timely charting in the Electric Health Record (EHR) system.

• Work closely with primary care providers and other health care professionals to ensure that patients receive coordinated, high-quality care. Act as a liaison between the patient and healthcare team, facilitating communication and addressing any concerns or discrepancies.

• Provide patients with relevant information on managing chronic conditions, including lifestyle modifications, medication management, and preventative care. Offer support and understanding and follow through with medical recommendations.

• Track patient progress, monitor for potential issues such as missed appointments or medication refills, and intervene when necessary. Ensure patients receive reminders for follow up appointments and preventive screenings.

• Collaborates with Administrative and Quality Improvement team in clinical program goal setting, progress evaluations and ongoing problem solving.

• Annual Wellness Visits (AWV)

• Conduct pre-visit outreach to patients to collect necessary health history, risk assessments, and screenings.

• Review and document preventative care needs, including vaccinations, screenings, and lifestyle modifications.

• Collaborate with providers to ensure accurate documentation and coding for Medicare AWVs.

• Maintain compliance with Medicare AWV guidelines, ensuring proper documentation and quality reporting.

• Assist with scheduling patient for AWVs and follow up on no-shows to ensure completion of visits.

• Transitional Care Management (TCM)

• Conduct outreach to patients with 48 hours of hospital discharge to access their needs and prevent readmissions.

• Review discharge instructions, ensuring patients understand their follow-up care and medication changes.

• Coordinate post-discharge care, including scheduling follow-up provider visits.

• Monitor patients for potential complications or signs of deterioration, escalating concerns to the appropriate healthcare provider.

• Work closely with providers and care teams to ensure patients receive appropriate follow-up care within 7-14 days post-discharge.

• Educate patients and caregivers on self-management strategies to improve recovery and reduce hospital readmissions risks.

• Telehealth

• Assist with virtual scheduling, ensuring patients and providers are prepared.

• Provide technical support to patient troubleshooting connectivity and access issues.

• Conduct routine equipment checks to ensure telehealth devices are functioning properly.

• Train staff and providers on telehealth platform usage and best practices.

• Ensure proper documentation in compliance with regulations.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The ideal applicant will demonstrate strong organizational and communication skills, attention to detail, and proficiency with virtual care tools.
• Experience with care plan adherence, chronic disease education, remote monitoring technology, and Medicare guidelines is preferred.
• Travel between LRMC sites may be required.
• The ability to work independently and think critically is essential.
• Bilingual skills in Spanish are a plus.

EDUCATION and/or EXPERIENCE

• A Licensed Practical Nurse with a minimum of 2 years in a clinical setting, required.
• Experience with quality programs and measuring patient outcomes is preferred.

CERTIFICATES, LICENSES, REGISTRATION

• Licensed Practical Nurse in the state of South Carolina or North Carolina.

LRMC offers benefits such as:

• Medical, Vision & Dental insurance.
• Employer matched 403B Retirement Plan.
• Paid Vacation time, Sick time, & Holiday's. As well as paid qualifying Administrative Leave.
• Employer Paid Health Benefits: Life / AD&D Policies, Short/Long Term Disability, and a Employee Assistant Plan.