Job Overview: This position provides both direct and indirect patient care in a primary care office and works with care delivery providers to identify gaps in care, contacts patients to schedule required care, and provides referral follow up. The Medical Home LPN provides pre-visit planning for the practice's patient panel, coordinates messages through electronic portals, and assists in managing transitions of care. The Medical Home LPN will act as a clinical liaison to the physician care plan and actively communicate with patients. The LPN participates in process improvements, is knowledgeable of clinical goals and outcomes including patient satisfaction and engagement. Other job-related duties may be assigned to meet the needs of the department. Must have strong skills in clinical care, customer service, communication, and teamwork. This role understands the needs of the organization and 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 preferred physician practice or related field Equivalent experience accepted in lieu of degree Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) Medical office flow, especially the 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 experience Clinical Healthcare Job Responsibilities: Coordinates the primary care rooming process, relevant medical procedures, adult and pediatric patient care including, immunizations, venipuncture, point of care testing, and performs retinal scan images. Follows scheduling decision tree, protocols and policies for clinical procedures and appropriate use of medical equipment. Provides accurate and complete documentation of all facets of care including clinical calls, patient rooming questions, completion of procedures, order entry, prescriptions and patient pharmacy, and workflows. Addresses messages in a timely manner and escalates issues as appropriate. Utilizes and monitors MyChart messaging to support patient communication Participates as a part of the patient centered medical home team during all patient visits by reviewing the patient chart of clinical gaps in care. Assist with outreach campaigns and tactics to close gaps in care. Supports and completes pre-visit planning and participates in daily huddles with the physician and care team. Embraces the philosophy of wellness and prevention by reminding patients of all screenings and immunizations due by the end of the year. Informs physician of any potential barrier identified by the patient. Understands population health and value-based contracts. Utilizes key quality and unitization metrics of value-based programs for both wellness and chronic disease management. Demonstrates abilities in the Primary Care quality program including all protocols of well and chronic disease states. Identifies patients "at risk" for change in condition and increased utilization. Attends required population health training and education such as Lunch and Learns and other opportunities Participates in the longitudinal care continuum of patients through completing post ED/post inpatient discharge outreach on identified risk patient group. Updates care team thorough documentation and works collaboratively with Complex Care RN, Social Worker, CHW, and Population Health Pharmacist. Provides basic community resources to patients with social determinates in health. Supports and provides education and patient coaching of both wellness and chronic disease management (e.g., Diabetes Education, Colon Cancer Screening). Supports facilitating follow-up for post-hospital care, chronic disease management, or specialty referral. Other Job