Evergreen Nephrology - Care Coordinator, LPN

• As a Licensed Practical Nurse (LPN) with Evergreen Nephrology, you are responsible for conducting monthly clinical check-ins, identifying and addressing clinical concerns, reinforcing care plans, escalating issues appropriately, and ensuring clinical documentation accuracy across both the EHR and partner technology platform. This position requires clinical judgment, licensed expertise, and the ability to support patients between office visits while collaborating closely with Evergreen’s providers, care teams, and leadership. LPNs are essential to delivering a safe, compliant, clinically credible Connected Care Program. • The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate. • While this position is fully remote, you must be able to work from 8:30am – 5pm in the Mountain time zone. • fully remote • Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following: • Perform monthly CCM touchpoints for assigned patient panels. • Build strong, ongoing relationships with patients and caregivers through regular outreach. • Review patient chart data (diagnoses, kidney disease history, medications, labs, imaging, treatment cycles) before calls. • Explain CCM participation and reinforce program benefits. • Conduct structured symptom assessments (pain, fatigue, neuropathy, SOB, nausea, etc.). • Evaluate changes in condition using licensed clinical judgment. • Assess medication adherence issues, side effects, or confusion about regimen. • Identify clinical red flags requiring escalation (e.g., worsening symptoms, new SOB, uncontrolled pain, concerning vitals). • Escalate urgent issues based on defined triage pathways (same-business-day or immediate). • Route EHR messages with clinically relevant documentation. • Assist in coordinating care: scheduling follow-up, arranging labs, ensuring nephrology appointments are kept, and reducing missed care. • Reinforce provider-developed CKD and chronic disease care plans. • Provide clinical explanation of symptom management instructions (within LPN scope). • Support adherence to medications, lifestyle changes, and follow-up instructions. • Identify social, behavioral, or access barriers and determine appropriate interventions or referrals. • Document all patient interactions clearly in both the EHR and CCM patient management platform. • Track and log qualifying CCM time accurately for billing compliance. • Ensure documentation meets regulatory, internal QA, and partner expectations. • Maintain high call quality and adherence to scripting and workflow pathways. • ≥80% monthly engagement • ≥90% billable conversion • High QA/documentation accuracy scores • Participate in peer reviews, QA audits, coaching sessions, and continuous education. • Identify recurring patient needs and communicate trends to the Program Manager. • Other duties consistent with this role, as assigned.