Job Overview:

This position provides both direct and indirect patient care in a primary care office, working with care delivery providers to identify gaps in care, contact patients to schedule required care, and provide referral follow-up. The Medical Home LPN is responsible for pre-visit planning for the practice's patient panel, coordinating messages through electronic portals, and assisting in managing transitions of care. The LPN acts as a clinical liaison to the physician care plan and communicates actively with patients. They participate in process improvements and are knowledgeable about clinical goals and outcomes, including patient satisfaction and engagement. Additional job-related duties may be assigned to meet the department's needs. Strong skills in clinical care, customer service, communication, and teamwork are required. The role supports the mission, values, and management of TriHealth Physician Practices.

 

Job Requirements:

Graduate of an approved technical, professional, or vocational program in Healthcare Healthcare clinical experience in a physician practice or related field preferred Equivalent experience accepted in lieu of degree Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) certifications Familiarity with medical office flow, including clerical/front office tasks Ability to make quick decisions based on well-thought-out consequences/results Knowledge of EMR, practice management software, and medical coding/billing strongly encouraged 3-4 years of experience in Clinical Healthcare  

Job Responsibilities:

Coordinate the primary care rooming process and relevant medical procedures for adult and pediatric patients, including immunizations, venipuncture, point-of-care testing, and retinal scans Follow scheduling decision trees, protocols, and policies for clinical procedures and the appropriate use of medical equipment Provide accurate and complete documentation of all facets of care, including clinical calls, patient rooming questions, completion of procedures, order entry, prescriptions, patient pharmacy, and workflows Address messages in a timely manner and escalate issues as appropriate Utilize and monitor MyChart messaging to support patient communication Participate as part of the patient-centered medical home team during all patient visits, reviewing patient charts for clinical gaps in care Assist with outreach campaigns and tactics to close gaps in care Support and complete pre-visit planning and participate in daily huddles with the physician and care team Embrace the philosophy of wellness and prevention by reminding patients of all screenings and immunizations due by the end of the year Inform the physician of any potential barriers identified by the patient Understand population health and value-based contracts, utilizing key quality and utilization metrics for wellness and chronic disease management Demonstrate abilities in the Primary Care quality program, including protocols for well and chronic disease states Identify patients "at risk" for changes in condition and increased utilization Attend required population health training and education, such as Lunch and Learns and other opportunities Participate in the longitudinal care continuum of patients through post-ED/post-inpatient discharge outreach for identified high-risk patient groups Update the care team with thorough documentation and collaborate with Complex Care RN, Social Worker, CHW, and Population Health Pharmacist Provide basic community resources to patients with social determinants of health Support and provide education and patient coaching on wellness and chronic disease management (e.g., Diabetes Education, Colon Cancer Screening) Facilitate follow-up for post-hospital care, chronic disease management, or specialty referral

Other Job-Related Information:

Age-related competencies, experience with multiple age groups, understanding of recommended screenings based on age groups, understanding of chronic disease management processes, and experience with patient-centered medical homes

 

Working Conditions:

Climbing: Occasionally Concentrating: Consistently Hearing (Conversation): Frequently Interpersonal Communication: Consistently Kneeling: Occasionally Lifting <10 Lbs: Consistently Lifting 50+ Lbs: Occasionally Lifting 11-50 Lbs: Rarely Pulling: Occasionally Pushing: Occasionally Reaching: Consistently Reading: Consistently Sitting: Consistently Standing: Frequently Stooping: Occasionally Thinking/Reasoning: Consistently Use of Hands: Consistently Color Vision: Consistently Walking: Consistently
 

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 

Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service 
Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community