Alopex

Bilingual

• Conduct detailed reviews of electronic medical records (EMR).
• Develop, implement, and maintain individualized care plans.
• Coordinate all care management activities across the continuum of care.
• Communicate effectively with patients, primary care providers, and interdisciplinary care teams.
• Perform timely care management and follow-up activities.
• Monitor and evaluate patient progress toward established outcomes.
• Maintain accurate and thorough documentation related to medications, diagnoses, goals, interventions, preventive care, and outcomes.
• Conduct monthly care coordination calls with enrolled patients.
• Address patient needs and concerns, including follow-up actions as required.
• Educate patients on chronic conditions and reinforce provider-directed treatment plans.
• Assess social determinants of health and connect patients with appropriate community resources; document accordingly.
• Identify and respond to changes in patient conditions in a clinically appropriate manner.
• Adhere to all Medicare, Shifox, and Alopex policies and procedures.
• Perform other duties as assigned.

LPN Care Coordinator, Bilingual Spanish Required