LVN, Care Manager

Heritage Provider Network•Victorville, CA

12d•Hybrid

About The Position

The LVN Care Manager optimizes patient care delivery and health outcomes by participating in the care management process in accordance with NCQA standards, CMS guidelines, health plan contracts, and company policy. Operating under the clinical direction and oversight of a Registered Nurse (RN), the LVN Care Manager gathers clinical and psychosocial data, utilizes health plan–completed Health Risk Assessments (HRAs), assists in drafting S.M.A.R.T. care plans, and coordinates multidisciplinary care to prevent unnecessary readmissions and promote adherence.

Requirements

Graduate of an accredited Licensed Vocational Nursing (LVN) program.
Current LVN license.
2 years of clinical nursing experience.
Knowledge of medical terminology.
Ability to utilize Microsoft Office programs/applications (Word, Outlook, Excel, Power Point) computers, computer software and applications.
Detail oriented.
Ability to manage time effectively and prioritize tasks to meet established deadlines.
Ability to effectively communicate with individuals within all levels of the organization, patients, patient family members, providers, vendors and others.

Responsibilities

Conduct telephonic, or office outreach to collect clinical, psychosocial, and functional data, leveraging completed health plan Health Risk Assessments (HRAs) to establish baseline patient needs and identify gaps in care.
Synthesize collected data to draft individualized S.M.A.R.T. (Specific, Measurable, Attainable, Realistic, Time-Bound) care plans, including proposed goals and interventions.
Task and submit all initial care plans, goal modifications, and ongoing updates to the designated RN for formal clinical evaluation and approval.
Manage an assigned caseload by conducting routine follow-up contacts to monitor member health status, assess progress toward care goals, and identify changing clinical needs.
Contact members post-hospitalization following transitional nurse calls to explain program benefits, initiate enrollment, and execute interventions that mitigate readmission risks.
Prepare case data for and actively participate in Interdisciplinary Team (IDT) meetings to review complex cases and align care coordination strategies.
Request updated physician orders from PCPs or specialists, review and coordinate patient referrals, and submit clinical documentation to support timely access to services and equipment.
Document all patient interactions, care coordination steps, readmission prevention efforts, and communication forms accurately in the EMR within established timeframes.
Educate members on condition self-management, organization offerings, and community resources, distributing welcome packets and educational materials as appropriate.
Perform other duties as assigned.