LVN SNP Case Management

Bakersfield Family Medical Group•Bakersfield, CA

4h•$30 - $35•Remote

About The Position

Under the direction of the Supervisor of Case Management, this remote position is responsible to complete an annual comprehensive assessment and care plan on each SNP (Special Needs Plan) patient for which BFMG/CCPN has identified. Special needs members are individuals with specific severe or disabling chronic conditions or are dually eligible for Medicare and Medi-cal. The nurse will provide regular follow-up, care coordination, and transitional care management services, in coordination with providers, other departments and the Patient Services Coordinator. The LVN Case Management will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

Requirements

Graduate from an accredited Vocational Nursing Program.
Current California LVN License.
Current BLS certification.
Ability to utilize EHR systems and electronic mail effectively.
Computer literacy.

Nice To Haves

Minimum of one-year clinical nursing experience.
Bilingual.

Responsibilities

Complete an annual comprehensive assessment and care plan on each SNP patient.
Provide regular follow-up, care coordination, and transitional care management services.
Interact with other departments, clinic personnel, and outside providers professionally and friendly.
Obtain and document all pertinent patient information in NextGen.
Evaluate SNP Master List weekly for patients due to be contacted for SNP Case Management.
Outreach patients telephonically within 90 days of enrollment into Special Needs Plan and present the SNP Case Management program with the option to accept or decline.
Complete a comprehensive assessment in compliance with NCQA, CMS and health plan guidelines based off of the outreach outcome: accepted case management, declined case management or unable to reach.
Comprehensive assessment to include patient’s self-management plan and goal, barriers and progress toward SMART care plan goals, caregiver resources, psychosocial assessment, DME, mental health status, medical status, medication review.
Retrieve the HRA (Health Risk Assessment) and assess for any identifiable issues/conditions and address those items in the care plan.
Task the RN for review and signoff of the completed comprehensive assessment.
Outreach patients telephonically after a transition of care has occurred and evaluate for any care coordination needs.
Make out bound calls to patients in between appointments to ensure care plan is being followed and necessary care is being received.
Assist with scheduling appointments or transportation.
Update care plan when there is a change in patient’s medical status, a transition of care, or, at minimum, annually.
Effective communication with all involved health care providers.
Be proactive with treatment options.
Evaluate patients appropriate for Complex Case Management and refer when needed.
Identify patients in need of community based resources and refer to Patient Services Coordinator.
Attend weekly SNP/IDCT meetings and present on patients who have accepted case management or who have had a transition of care.
Be available to receive incoming patient calls needing care coordination or triage.
Receive RN oversite for review of any required documentation and/or patient care needs as directed under licensed scope of practice.
Attend office visits with complex patients when scheduled in Staff Clinic when appropriate.
Follow up on any orders given by a Staff Provider.
Ensure necessary referrals are submitted.
Refill maintenance medications as appropriate when requested by patients or pharmacies.
Be prepared to assist with covering fellow Case Managers during vacation and/or time off.
Discuss complex cases with Supervisor to formulate an action plan.
Complete Culture and Linguistics Training annually.
Perform other duties as assigned.