LVN Case Manager PHM- Bakersfield 1.2

Universal Healthcare MSO LLC•Bakersfield, CA

10d•$32 - $40•Onsite

About The Position

The LVN Nurse Case Manager provides direct case management support to members across the Population Health Management (PHM) continuum, serving individuals with needs ranging from low-risk preventive care to complex case management. The LVN collaborates with the interdisciplinary care team to deliver enhanced care coordination, assist with individualized care plan development, monitor clinical and social service interventions, and support member engagement in self-management goals. This position focuses on addressing medical, behavioral health, and social determinants of health needs to improve outcomes, reduce avoidable utilization, and enhance the member experience. The position may also require assignment at a designated clinic site, where the LVN will provide case management services in collaboration with the care team, providers, and members.

Requirements

Current, unrestricted Licensed Vocational Nurse (LVN) license in the State of California.
Valid driver’s license and reliable transportation for community-based and clinic assignments.
Minimum of 2 years clinical nursing experience, preferably in case management, primary care, or managed care.
Demonstrated knowledge of nursing processes, case management, and continuity of care.
Ability to work with members to influence behavior through care goal negotiation and support of self-management.
Sensitivity to members' social, cultural, language, physical, and financial differences.
Ability to respect and support the needs of members, caregivers, and team members while providing excellent customer service.
Strong problem-solving skills, with the ability to identify issues and propose effective solutions.
Ability to prioritize and adapt to changes in member situations and needs.
Strong organizational skills, with the ability to work independently while managing multiple tasks throughout the day.
Excellent verbal and written communication skills, including the ability to explain complex health and benefit information in a clear manner.
Proficiency in the use of electronic case management systems and technical proficiency in Microsoft Office (Word, Excel, PowerPoint), databases, and internet-based tools.
High attention to detail with accuracy, thoroughness, and persistence in documentation and follow-up.
Ability to work effectively both independently and as part of an interdisciplinary team, while adapting to changing environments.
Commitment to professionalism, continuous learning, and quality improvement.
Ability to always maintain confidentiality and professionalism.

Nice To Haves

Experience working with high-risk or vulnerable populations preferred (e.g., Medi-Cal, Medicare, D-SNP, ECM).

Responsibilities

Effectively manage and maintain a caseload of assigned members, ranging from low-risk preventive outreach to members with complex medical and social needs.
Conduct comprehensive assessments to develop individualized, person-centered care plans in collaboration with the member, caregiver(s), and care team.
Ensure care plans incorporate physical health, behavioral health, substance use disorder, LTSS, palliative care, community services, housing, and other identified needs.
Provide culturally appropriate and accessible communication with members through telephonic, virtual, and in-person outreach. Case managers may also attend critical appointments with members to support care plan execution and address barriers to engagement. Reassess members at a frequency appropriate for their risk level, progress, or changes in needs, ensuring care plans are updated under appropriate clinical oversight.
Coordinate services necessary to implement the care plan, ensuring continuity and integration of care across primary care, specialists, behavioral health, pharmacy, and community-based providers.
Organize and participate in Interdisciplinary Care Team (ICT) meetings to review member care plans, update progress, and ensure member-centered care.
Provide education, coaching, and motivational interviewing to encourage lifestyle changes and support effective self-management skills.
Support member engagement by coordinating medication review and/or reconciliation, scheduling appointments, providing reminders, arranging transportation, accompanying members to critical appointments, and addressing barriers to engagement.
Deliver transitional care services, including discharge risk assessments, post-discharge follow-up, medication reconciliation, contingency planning, and coordination of post discharge services (home health, DME, transportation, prescriptions, follow-up visits).
Ensure closed-loop referrals to community supports, housing, and social service agencies, with follow-up to confirm services were delivered, including authorizations issued by the organization for care services.
Monitor member conditions, health status, medications, and care planning on an ongoing basis, escalating changes to the RN Case Manager or clinical leadership as appropriate.
Support quality improvement by helping close HEDIS, MCAS, STARs, and SNP MOC gaps in care.
Accurately and timely document all case management activities in the electronic health record (EHR).
Collaborate with RN Case Managers, Medical Directors, and leadership on clinical documentation, care plan reviews, and member care needs.
Maintain working knowledge of available community resources to address member needs, including SDOH barriers.
Participate in daily huddles, departmental meetings, ICTs, and staff trainings.
Assist with training and orientation of new staff, as requested.
Perform other duties as assigned.