Nurse Discharge Planner LVN - CalAIM

Wellpath•Santa Rosa, CA

About The Position

The Nurse Discharge Planner LVN develops and coordinates clinically informed reentry care plans for CalAIM-eligible individuals, addressing medical, behavioral health, and substance use needs before release. The role conducts basic nursing assessments, reviews health records, coordinates referrals, and facilitates warm handoffs to managed care plans and community providers. It supports timely service delivery by documenting services in the electronic health record, tracking release timelines, activating Justice-Involved aid codes, and collaborating with in-reach partners and Medi-Cal eligibility staff. The position provides discharge planning for medical, mental health, medication-assisted treatment (MAT), and related programs in accordance with contract requirements and policies. It coordinates medications and other medical needs upon release, arranges community referrals and appointments, facilitates psychoeducational sessions and benefit applications, and supports the resumption of services. The role maintains working relationships with facility staff and community partners while complying with security regulations and DHCS CalAIM requirements. An evening shift differential of 7.5% is noted.

Requirements

  • Graduation from an accredited School of Nursing.
  • Current licensure as a Licensed Practical/Licensed Vocational Nurse in the state of employment, which must be maintained.
  • IV certification.
  • Maintain CPR certification and any other certifications, such as First Aid, required by contract.
  • Ability to attain and maintain security clearance to the facility.
  • Reside in the United States.

Nice To Haves

  • Bachelor's degree in Social Work, Business Administration, or another health-related field from an accredited college or university.
  • Previous experience developing successful transition plans involving community resources for people with medical, substance use, and/or mental illness.

Responsibilities

  • Provide discharge planning services for medical, mental health, MAT, and related programs in accordance with contract requirements and policies.
  • Identify release-planning needs, coordinate medications and medical needs upon release, and arrange referrals and appointments with community providers.
  • Facilitate psychoeducational sessions, benefit applications, and resumption of services to support continuity of care.
  • Maintain working relationships with facility staff, parole, mental health, and medical partners while adhering to security regulations.
  • Document services in the health record, activate Justice-Involved aid codes, and ensure compliance with DHCS CalAIM requirements.
  • Conduct basic nursing assessments, review health records, coordinate referrals, facilitate warm handoffs, and track release timelines.

Benefits

  • Medical, dental, and vision benefits
  • Paid time off
  • 401(k)
  • DailyPay
  • Tuition assistance and dependent scholarships
  • Employee Assistance Program (EAP), including free counseling and health coaching
  • Company-paid life insurance
  • Tax-free Health Spending Accounts (HSA)
  • Wellness program featuring fitness memberships and product discounts
  • Preferred banking partnership and discounted rates for home and auto loans
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