LPN Care Coordinator, Embedded (Prince Georges County, MD)

📋 Description

• • **Join Ennoble Care: Where Compassion Meets Innovation in Patient Care**
• • Ennoble Care is a leading provider of mobile primary care, palliative care, and hospice services, dedicated to bringing high-quality healthcare directly to patients in their homes. With a presence across multiple states, including New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, and Georgia, we are committed to ensuring that individuals with chronic conditions and limited mobility receive continuous, trusted care. Our comprehensive approach includes remote patient monitoring, behavioral health management, and chronic care management, all delivered by a team that embodies our core motto: “To Care is an Honor.” We are actively seeking a dedicated and compassionate Licensed Practical Nurse (LPN) to serve as an **Embedded Care Coordinator** within our partnered long-term care facilities in Prince George's County, Maryland.
• • This is a unique opportunity to become an integral part of our clinical care team, working on-site within skilled nursing and rehabilitation facilities. As an LPN Embedded Care Coordinator, you will be a vital link in our patient-centered model, fostering strong relationships with residents, their families, and facility staff. Your role will focus on ensuring continuity of care, monitoring residents for changes in their condition, and playing a hands-on part in helping individuals maintain their health, avoid unnecessary hospitalizations, and remain in their preferred living environment.
• • At Ennoble Care, we pride ourselves on cultivating a positive, respectful, and collaborative work environment. We believe in valuing our team members, supporting them in meaningful work, and promoting a healthy work-life balance. We are committed to professional growth, offering internal advancement opportunities based on performance and organizational needs, because we understand that our team's success directly contributes to our patients' well-being.
• • *About the Role:**
• • As an LPN Embedded Care Coordinator, you will be instrumental in bringing Ennoble Care's mission of "To Care is an Honor" to life. You will operate directly within one or more skilled nursing and rehabilitation facilities in Prince George's County, Maryland. Your primary focus will be on transitional care management, vigilant patient monitoring, and seamless day-to-day collaboration with our clinical team and facility personnel. You will act as a crucial communication bridge, connecting residents, families, facility staff, and our Housecalls division, ensuring that all parties are informed and that patient care remains on track and aligned with best practices.
• • *Key Responsibilities and Impact:**
• • **Transitional Care Management Excellence:** Facilitate the smooth transition of patients from hospital settings to our care, ensuring that Ennoble Care’s Housecalls division services are initiated promptly. Expedite the time to the first provider visit for newly transitioned patients, adhering strictly to established guidelines to ensure timely and effective care initiation.
• • **Proactive Patient Monitoring and Intervention:** Conduct attentive patient monitoring, identifying and promptly communicating any changes in condition to the assigned provider. Initiate appropriate clinical interventions and escalate care as clinically indicated, including managing and documenting Chronic Care Management (CCM) billable activities to ensure comprehensive patient support.
• • **Reducing Hospitalizations and ED Visits:** Consistently champion and execute care coordination efforts aimed at reducing avoidable emergency department visits and hospital readmissions. Your vigilance and proactive approach will directly contribute to improved patient outcomes and resource optimization.
• • **Building Strong Resident Relationships:** Maintain a consistent and reliable daily on-site presence within your assigned facilities. Build and nurture ongoing relationships with residents and their families, fostering an environment of trust and continuity of care that is central to our patient-centered philosophy.
• • **Seamless Communication and Collaboration:** Serve as a key liaison between Ennoble Care providers, facility staff, residents, families, and the Housecalls team. Collaborate closely with Ennoble Care providers within the facility setting, providing timely and accurate clinical updates to support informed decision-making and coordinated care planning.
• • **Driving Patient Engagement:** Actively work to convert eligible patients to Ennoble Care's Housecalls program, aiming to engage two patients per day. You will be a steady communication bridge, ensuring accurate and timely exchange of clinical information among all stakeholders.
• • **On-Site Clinical Support:** Conduct routine and urgent vital sign collection as needed, perform regular patient check-ins to support care plans, follow-ups, and clinical stability. Identify subtle changes in patient condition and proactively communicate concerns to the clinical team, ensuring prompt and appropriate action.
• • **Accurate and Compliant Documentation:** Accurately document all patient interactions, assessments, and care coordination activities within Ennoble Care’s Electronic Medical Record (EMR) system. Perform thorough chart reconciliation to ensure the accuracy and continuity of clinical records between Ennoble Care and facility records, adhering to all established workflows, documentation standards, and escalation protocols.
• • **Team Mentorship and Support:** Support the onboarding and training of new Embedded Care Coordinators, serving as a clinical mentor and resource. Promote best practices in transitional care, communication, and facility-based care coordination, contributing positively to team collaboration and fostering strong partnerships with facility staff.
• • This role offers a dynamic work environment where your clinical skills, communication abilities, and compassionate approach will make a tangible difference in the lives of patients. You will be part of a team that values dedication, collaboration, and a commitment to providing exceptional care.