layiq

/la·yiq/adjective

worthy; deserving; fitting; suitable.

A role, opportunity, or path that merits attention, time, and pursuit.

LPN Transitional Care Coordinator (Prince Georges County, MD) at Ennoble Care | LAYIQ

Care Coordination & Transitional Care Management
Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR
Facilitate transitional care management, ensuring services with the Housecalls division are initiated immediately upon a patient's discharge from the hospital
Expedite time to first provider visit for newly transitioned patients in accordance with established guidelines
Monitor patients attentively, communicate changes in condition promptly to the provider, initiate appropriate interventions, and escalate care as clinically indicated, including CCM-billable activities
Consistently support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions
Collaborate daily with providers and facility staff to ensure care plans are kept current and acted on On-Site Clinical Support
Maintain a consistent and reliable daily on-site presence in assigned facilities
Build ongoing relationships with residents and their families, maintaining a consistent presence that reinforces trust and continuity of care over time
Conduct routine and urgent vital sign collection as needed
Perform regular patient check-ins to support care plans, follow-ups, and clinical stability
Identify changes in patient condition and promptly communicate concerns to the clinical team
Communication & Collaboration
Serve as a key liaison between Ennoble Care providers, facility staff, residents, families, and the Housecalls team
Collaborate closely with Ennoble Care providers within the skilled nursing or long-term care setting
Provide timely, accurate clinical updates to providers to support informed decision-making
Ability to convert two (2) eligible patients per day to Ennoble Care's Housecalls program
Serve as a steady communication bridge between residents, families, the facility team, and our Housecalls division
Function as a reliable communication bridge to ensure accurate, timely exchange of clinical information
Documentation & EMR Management
Accurately document patient interactions, assessments, and care coordination activities in Ennoble Care’s EMR
Perform chart reconciliation to ensure accuracy and continuity of clinical records between Ennoble and facility records
Follow established workflows, documentation standards, and escalation protocols
Team Support & Leadership
Support onboarding and training of new Transitional Care Coordinators
Serve as a clinical mentor and resource for newly hired coordinators
Promote best practices in transitional care, communication, and facility-based care coordination
Contribute positively to team collaboration and foster strong partnerships with facility staff
Work Environment & Expectations
Embedded, on-site role within assigned skilled nursing and/or rehabilitation facilities
Requires consistent daily presence and strong relationship-building with facility staff
Fast-paced, patient-facing role requiring clinical judgment, adaptability, and proactive engagement
CORE COMPENTACIES
Patient-centered care
Clinical judgment and escalation
Care coordination and continuity
Communication and collaboration
Documentation accuracy and compliance
Relationship-building and teamwork

LPN Transitional Care Coordinator (Prince Georges County, MD)

Employer job description

About Us

ABOUT THE ROLE

At Ennoble Care, our mission is simple:

Transportation criteria:

KEY RESPONSIBILITIES

COMPENSATION & BENEFITS

All employees qualify for these benefits:

Equal opportunity and accommodations

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