LVN Case Management

Bakersfield Family Medical Group•Bakersfield, CA

1d•$30 - $35•Onsite

About The Position

Under the direction of the Supervisor, the LVN Case Manager assesses, diagnoses, plans, implements, and evaluates patients enrolled in complex case management. The role coordinates each patient's plan of care with providers in the Priority Care Program, completes annual comprehensive assessments and care plans for delegated patients, supports care coordination, and provides ongoing education and resources to patients and caregivers to help prevent avoidable emergency room use. The Case Manager attends patient appointments at the onsite Priority Care Clinic and carries out provider orders, which may include medication and lab orders, referrals, patient education, basic wound care, EKGs, subcutaneous and intramuscular injections, ear lavages, and venipuncture. The Case Manager collaborates with the medical team to improve health outcomes and help patients stabilize, graduate from Priority Care, and resume care with their assigned Primary Care Provider. The role works professionally and collaboratively with internal departments, clinic personnel, outside providers, patients, and families.

Requirements

Graduation from an accredited Licensed Vocational Nursing program.
Current California LVN license.
Current Basic Life Support (BLS) certificate.
At least two years of clinical nursing experience.
Knowledge of Microsoft Office, including Microsoft Word and Excel.
Computer literacy, including typing skills.
Ability to be flexible, adaptable, and motivated; maintain a positive attitude; and work as a team player.

Responsibilities

Obtain and document pertinent patient information and notes in NextGen.
Maintain positive, professional relationships with providers, patients, families, clinic personnel, and outside providers, and communicate effectively with healthcare providers, including specialists.
Attend scheduled patient office visits in the Priority Care Clinic and carry out provider orders in a timely manner.
Evaluate patient acuity using clinical criteria and update the assigned level as needed: Level 1A high acuity with weekly follow-up; Level 1B moderate acuity with biweekly follow-up; and Level 2A low acuity with monthly follow-up.
Contact patients and document contacts in NextGen according to their assigned acuity level.
Complete annual comprehensive assessments, with an RN reviewing the LVN document. Initiate assessments within 30 days of referral and complete them within 60 days.
Assess clinical history, self-reported health status and goals, care plans and progress, barriers, medication reconciliation, social history, caregiver resources, hearing and vision, benefits, community resources, interdisciplinary care team members, follow-up plans, health screenings, life planning activities, and assessment conclusions.
Create and maintain comprehensive, working care plans in accordance with NCQA, CMS, and health plan guidelines, with input from the interdisciplinary care team and the patient or caregiver.
Set and prioritize appropriate patient-centered SMART goals.
Maintain an updated patient brain sheet with past and present medical history, clinical data, and specialty appointment information.
Obtain recent medical records before scheduled appointments and present them to the provider.
Review provider orders with patients or caregivers to ensure understanding, and provide needed education or teaching. Orders may include medications, labs, referrals, basic wound care, EKGs, injections, ear lavages, and venipuncture.
Contact patients within three days after a transition of care, review the plan of care, follow through on discharge orders, and update care plans accordingly.
Update care plans when a patient's medical status changes.
Apply knowledge of disease processes, labs, and medications to assess patient needs and provide education.
Coordinate Social Services and/or Patient Services Coordinator support for patients and families to help them cope with illness and access health services.
Mobilize resources and intervene as needed to achieve expected goals and clinical outcomes within the desired timeframe.
Be proactive with treatment options and support timely admissions and discharges from Priority Care.
Facilitate a smooth transition back to the Primary Care Provider after discharge from Priority Care.
Initiate or participate in Code Red, Code White, and Code Blue situations as directed.
Maintain familiarity with BFMC's clinical structure and contracted healthcare services.
Understand patient healthcare benefits and help establish expectations for services within benefit limits.
Serve as the designated point of contact for patients and caregivers regarding health needs, collaborating with providers to facilitate orders in a timely manner.
Educate and assist patients with decisions about end-of-life care, including advance directives, durable powers of attorney, and POLST forms.