LICENSED VOCATIONAL NURSE-LCM (Sacramento Area)

Blehealth•Sacramento, CA

21h•Remote

About The Position

The Lead Care Manager (LVN) works collaboratively with chronically ill or high-risk members and their families or caregivers, health care providers and staff, and community resources. The role coordinates services, engages eligible members, oversees Enhanced Care Management (ECM) services and care-plan implementation, and connects members with appropriate health care and social supports. Services may be provided where members live, seek care, or can most easily access them, in accordance with applicable health plan guidelines. The Lead Care Manager assesses members’ health and social needs; develops and monitors individualized care plans with members, caregivers, and providers; supports transitions of care and referrals; and helps members access medical, specialty, and community services, including transportation. The role also provides health education and self-management support, advocates for members, promotes care-plan adherence and continuity of care, and communicates with members and care teams through in-person visits, email, phone, text, and other channels. The position is remote, but requires occasional reporting to a satellite office or specified location for work, meetings, or training, as well as visits to hospitals and members’ homes as needed.

Requirements

Current, valid Licensed Vocational Nurse (LVN) license in California.
At least 1 year of experience.
Bachelor’s degree, as listed in the posting.
Valid driver’s license, proof of insurance, a good driving record, and a reliable means of transportation; the role includes a monthly mileage reimbursement per applicable state and federal laws.
Proof of a negative TB test and BLS/CPR certification before the hire date.
Successful completion of a Live Scan fingerprint and background check.
Proficiency with communication technologies such as email and cell phones.
Strong organization and ability to maintain accurate notes and records.
Excellent analytical, problem-solving, and prioritization skills.
Excellent verbal and written communication skills and high-level interpersonal skills.
Ability to work collaboratively and tactfully with multidisciplinary and diverse teams, including employees, customers, and physicians.
Effective computer skills, particularly with Microsoft Office, Excel, PowerPoint, and Word.
Ability to work independently and complete assigned tasks.
Skills in team building, project management, change management, quality and process improvement tools, and project execution.
Ability to report occasionally to a satellite office or specified location for work, meetings, or training, and to visit hospitals and members’ homes as needed.

Nice To Haves

Experience with health IT systems and reports.
Local knowledge of and connections to community health care and social welfare resources.
Bilingual ability in Chinese, Mandarin, or Spanish.

Responsibilities

Coordinate with members, caregivers, providers, and community resources to ensure a seamless experience and avoid duplication of services.
Engage eligible members and oversee provision of ECM services and implementation of care plans.
Provide services where members live, seek care, or can most easily access them, consistent with health plan guidelines.
Connect members to social services, community resources, and other supports, including arranging transportation.
Advocate for members with health care professionals and serve as a contact point, advocate, and informational resource for members, care teams, caregivers, payers, and community resources.
Use motivational interviewing, trauma-informed care, and harm-reduction approaches.
Coordinate with hospital staff on discharge plans and support transitions in care.
Accompany members to office visits as needed and in accordance with plan guidelines.
Monitor adherence to treatment, including medication, and to care plans; evaluate effectiveness and member progress, and facilitate changes as needed.
Provide health promotion, self-management training, and culturally and linguistically appropriate education.
Promote timely access to appropriate care and preventive care, and work to reduce emergency room use and hospital readmissions.
Develop care plans with members, caregivers, and providers, including emergency plans, health management plans, medical summaries, and ongoing action plans as appropriate.
Assess members’ unmet health and social needs and work with members to plan and monitor care.
Establish processes for members and caregivers to determine and request their desired level of care-coordination support.
Facilitate access to appropriate medical and specialty providers, and cultivate primary care and specialty provider co-management through timely communication, inquiry, follow-up, and integration of information into care plans.
Facilitate and attend meetings among members, caregivers, care teams, payers, and community resources as needed.
Identify high-risk members, including chronically ill people and people with special health care needs, and add them to the member registry or flag them in the EHR.
Follow up with members, caregivers, providers, and community resources through face-to-face visits, secure email, phone calls, text messages, and other communications.
Call members to coordinate visits at their homes or in hospitals as needed.
Attend all Lead Care Manager training courses, webinars, and meetings.
Provide feedback to improve the ECM Program.
Consistently achieve a minimum daily expectation of 30 schedules per day.