LPN Care Coordinator-Population Health

Whatever the role, everyone at Grady is part of something bigger. Choosing a career at Grady is choosing to be part of a legacy of service and commitment to our communities. If you want to make a difference, we want to hear from you.

Job Summary

Identifies high risk inpatients using risk stratification that are appropriate for RPM, MIH visit or both and collaborates with inpatient (IP) treatment teams regarding program referral.

Contacts patient to introduce PH program, gain consent and schedule patient for MIH visits once discharged from hospital/enrollment from clinic. Contacts patient and completes outreach call for hospital discharge patients.

Monitors daily RPM biometric results, survey questions, and escalates unresolved issues to MIH APP per protocol. Provides ongoing health education about the patients' current illness, medications, nutrition, and exercise.

Monitors the patients personalized care plan created by the patient and provider to ensure progression toward goals. Routinely contacts the patient via video/text or phone weekly to evaluate and document progression towards goals.

Consults and coordinates follow up care with MIH APP, patient's primary care provider or specialty provider to help them recover from any illness and return to their baseline.

Promotes and encourages patients and families to learn and participate in the management of their illness or complex health issues and reach their goals.

Serves as a point of contact, advocate, and informational resource to the patients and families, care team, payers, and community resources.

Manages kit logistics for remote monitoring program. TCM Program Responsibilities

Identifies patients for TCM outreach using Epic reports and established prioritization criteria.

Performs outreach to recently discharged patients to assess readmission risk factors including signs and symptoms of concern, medication issues, understanding of discharge instructions and education needs.

Identifies and addresses patient-level concerns regarding discharge by referring issues of urgent/emergent concern to appropriate provider, site of care, program for follow up in accordance with escalation protocols.

Addresses readmission risk factors through coordination of timely follow-up care with appropriate provider(s); patient education; resolution of medication discrepancies and/or challenges obtaining prescribed medications.

Communicates with all entities involved in the patient's care, as necessary, to promote and maximize care coordination, including PCP, MIH, TOC, discharging provider, inpatient Care Manager/ Social Worker, home care agency, DME/ medical supply vendor, pharmacy, clinic based Social Worker, clinic based or central Pharmacist.

Participates in and contributes to departmental safety huddle.

Connects patients with internal GHS resources/programs and community resources that help patients and families manage their illness and maintain healthy lifestyles. Examples of community resources include housing, food, transportation, medication assistance programs, nutrition, exercise, smoking cessation programs and behavioral health resources.

Document all patient encounters including assessment results, interventions and follow up in RPM or EPIC EMR.

Qualifications:

• Two years of college course work, Bachelors degree preferred

• LPN

• BLS

• Experience with EMR and computerized charting or Epic Systems/Epic Reports

• Three (3) or more years of experience in clinical or community resource settings, care coordination, and or case management experience.

Core Competencies
These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

1. Patient-Centered Care - Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.
2.Integrity & Accountability - Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
3.Collaboration & Teamwork - Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
4. Communication - Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
5.Respect & Inclusion - Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.
6. Quality & Safety - Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.
7. Adaptability & Resilience - Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.
8. Continuous Improvement - Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.
9. Leadership & Professionalism - Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.
10. Employee Experience Focus - Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.

Grady Total Rewards
At Grady, we believe in supporting the health, well-being, and growth of every team member. Our Total Rewards package is designed to provide competitive pay and comprehensive benefits that make a difference in your life and career, including:

• Health & Wellness: Medical, dental, vision, and prescription drug coverage.

• Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.

• Work-Life Balance: Paid time off, holidays, and family leave benefits.

• Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.

• Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.

Grady's Total Rewards are designed to ensure our employees feel valued, supported, and empowered, both at work and beyond.

Why Join Grady?
Grady Health System is more than a hospital - we are a vital part of Atlanta and the surrounding communities. For over 125 years, Grady has been committed to providing exceptional care, advancing health equity, and making a difference in the lives of those we serve. When you join Grady, you become part of a team that values excellence, compassion, innovation, and collaboration.

Here, every role matters. Whether you provide direct patient care, support our operations, or lead teams, you play an important part in fulfilling our mission. We offer opportunities to learn, grow, and build a meaningful career in an environment where your contributions are recognized and valued.

At Grady, we don't just work, we make an impact.

Equal Opportunity Employer Statement:
Grady Health System is proud to be an equal opportunity employer. We are committed to fostering a workforce where all employees feel valued, respected, and empowered to succeed. We prohibit discrimination and harassment of any kind based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.

Grady is dedicated to creating an accessible work environment and provides reasonable accommodations to qualified individuals with disabilities to ensure equitable opportunities for success.