LVN / LPN - Case Manager

Carenest Health Services • Rochester, NY

1d • Hybrid

About The Position

This role will support the Transitions of Care program, which focuses on reducing 30-day readmission rates. LPNs will work under the direction of the RN Care Manager to assist with implementing the care plan. This is not a hands-on nursing role. Responsibilities include, but are not limited to, appointment scheduling, biometric data monitoring, providing and reinforcing education, attending patient visits as needed, completing home visits, connecting patients with community resources, maintaining frequent patient contact, and completing other tasks as directed by the RN. The LPN will be part of a multidisciplinary care team that includes an RN, Social Worker, Pharmacist, and other professionals. Clear and concise communication and documentation skills are essential, as the LPN will document in the EHR. The ideal candidate must be able to work independently and remain flexible throughout the day. Responsibilities will also include attending care team rounds to provide patient updates and managing a monthly rolling caseload of approximately 25–30 patients. Access to reliable transportation is required, as travel may be necessary during the workday. LPNs will not transport patients. Clinical knowledge or experience with CHF, COPD, and multiple complex comorbidities is preferred. Patient Diagnoses: Transitions of Care Program - decrease admission rates Remote work - but could be required to go to patients home or providers office to observe or educate patients Work with RN to implement POC Remote / hospital setting - screen and see pts, telephonic work f/u appointments - triage barriers education taking meds appropriately align with community services screening calls - scoring documents Triage Care Team Rounds (virtual) - social worker / pharmacy / multi disciplinary team

Requirements

• LPN
• 1 year of experience
• Home Health/Mobile Case Management experience
• BLS Required
• Clear and concise communication skills
• Documentation skills
• Ability to work independently
• Flexibility
• Access to reliable transportation
• Community resource knowledge
• No hands-on care

Nice To Haves

• Clinical knowledge or experience with CHF, COPD, and multiple complex comorbidities
• Experience with Transitions of Care program
• Experience with remote work

Responsibilities

• Appointment scheduling
• Biometric data monitoring
• Providing and reinforcing education
• Attending patient visits as needed
• Completing home visits
• Connecting patients with community resources
• Maintaining frequent patient contact
• Completing other tasks as directed by the RN
• Documenting in the EHR
• Attending care team rounds to provide patient updates
• Managing a monthly rolling caseload of approximately 25–30 patients
• Screen and see patients
• Telephonic work
• Follow-up appointments
• Triage barriers
• Education on taking medications appropriately
• Align with community services
• Screening calls
• Scoring documents
• Triage
• Care Team Rounds (virtual)
• Reassess goals for the 30-day program
• Close or transition to long-term management program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree