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EVMS Care Manager I in Portsmouth, Virginia

This is a full time position for an LPN, providing care coordination and management to patients assigned to primary care practices. This includes the provision of care coordination services to include Medicare Wellness Visits, Care Management of Chronic Diseases, and Transitional Care Management for high risk patients, and quality outcomes for chronic disease management and prevention.

*The location of this position is Portsmouth, VA.

Coordinates and provides Medicare Wellness Visits to eligible patients in the primary care practice. Will complete documentation according to guidelines.

Work with Medical Assistant and other practice team members to include review of patient lists, quality measures, outreach lists and coordinate care for those members who are in need of Medicare Wellness Visits or identified as having quality gaps.

Will attend Care Management Meetings, Primary Care Collaborative meetings, and other educational sessions as scheduled. Will complete recommended educational modules as assigned.

Will follow chronic disease and preventive care guidelines and ensure that appropriate plans for completion are developed.

Assists patients in developing a personalized wellness plan that includes realistic goals and a plan of action, including advanced care planning.

Provides education and supports patients in learning how to make good choices for themselves that will lead to optimal well-being and a higher quality of life.

Works closely and coordinates care with the medical team, local pharmacists and other community services for optimal patient care and coordination.

Provides consistent and meaningful bi-directional communication to all healthcare providers to enhance care coordination and patient outcomes.

Promotes patient engagement and compliance with appointments, treatment recommendations and other recommended services.

Completes all tracking and reporting requirements for outcomes and evaluation.

Maintains appropriate professional standards including confidentiality and provides appropriate follow-up for patients.

Scans upcoming appointments for additional medical record information necessary. Obtains and reviews medical records from other physician offices, hospitals, labs, emergency rooms, and radiology departments prior to patient visit and when appropriate telephones patient in advance of visit.

Completes medication, allergy, and problem reconciliation tasks at each appointment follows other practice standing order protocols.

Appropriately document all interventions and contacts with patients.

Respond to questions from patients, family members, faculty/residents, other health care providers in a timely and professional manner. Patient phone calls should be answered on the same day they are logged in, before leaving for the day. If patient is not home at the first attempt, a notation should be made in the medical record. All patient conversations must be documented in the electronic medical record.

Performs other duties as assigned.

Completion of a program of instruction for licensure as a Practical Nurse and possession of a current Virginia license. Two (2) years of experience as an LPN. Completion of BLS class and re-certification every 2 years. Possess basic knowledge of educational behavioral approaches to change behavior.


Position Number: 6092001

Department: Family & Community Medicine

Grade: 14

External Company Name: Eastern Virginia Medical School

External Company URL:

Street: 600 Crawford Street