Job Description
Job DescriptionJob Title: Licensed Vocational Nurse (LVN) – Care Management
Department: Medical Management
Reports To: Director of Medical Management
Status: Full-Time / Non-Exempt
Location: Remote, potential hybrid position
Position Summary
The Licensed Vocational Nurse (LVN) – Care Management plays a key role in supporting patient-centered care coordination across the continuum. This position assists in proactive outreach, chronic disease management, transitional care follow-up, patient education, and closing care gaps. The LVN collaborates closely with Registered Nurses, providers, care coordinators, and other healthcare disciplines to promote quality outcomes, patient satisfaction, and cost-effective care.
Essential Duties & Responsibilities
- Conduct structured outreach calls to patients enrolled in care management programs (e.g., Chronic Care Management—CCM, Transitional Care, Complex Care, High-Risk Programs).
- Perform timely post-discharge follow-ups to ensure medication adherence, appointment scheduling, symptom review, and identification of barriers to care.
- Assist in development and documentation of patient-centered care plans based on goals, risk factors, and provider direction.
- Monitor and support patients with chronic conditions through education and self-management reinforcement.
- Identify and escalate clinical concerns or red-flag symptoms to RN or provider promptly.
- Maintain accurate, detailed documentation in the electronic medical record (EMR), ensuring compliance with CMS, payer, and organizational standards.
- Review and close care gaps including labs, preventive care, and specialty follow-up.
- Coordinate services such as DME, Home Health, or Community Resource referrals as directed by RN or provider.
- Support population health initiatives related to quality metrics, risk adjustment, and value-based care.
- Participate in interdisciplinary huddles, case conferences, and workflow improvement initiatives.
Required Qualifications
- Active California LVN License in good standing (or state required)
- Current BLS/CPR Certification
- Minimum 1 year of clinical experience in outpatient, care management, home health, or related setting
- Strong telephonic communication skills with the ability to build rapport and motivate patients
- Proficient in EMR documentation and basic computer systems
Preferred Qualifications
- Experience in Chronic Care Management (CCM), Population Health, ACO programs, or Case Management
- Knowledge of CMS quality programs and healthcare payer requirements
- Bilingual in English/Spanish
Key Competencies
- Patient advocacy and customer service excellence
- Critical thinking and clinical judgment
- Team collaboration and effective communication
- Time management and task prioritization
- Adaptability in fast-paced environment
- Understanding of social determinants of health (SDOH)
Physical & Work Requirements
- Ability to sit, type, and speak by phone for extended periods
- Remote environment with compliance to HIPAA guidelines
Mission & Culture
This role supports a collaborative care model that honors the patient’s voice, improves access to care, and enhances quality of life. The LVN contributes to a supportive team environment that values integrity, accountability, and continuous improvement.
Mon - Fri (8 am - 5 pm)