ECM Case Manager - LVN (Lancaster Region)

Ecm Case Manager (Lvn)

The ECM Case Manager (LVN) provides clinically informed care management, under the supervision and direction of the Manager, Strategy & Operations & RN Clinical Consultant, to a caseload of high-need Medi-Cal members enrolled in Astrana Health's Enhanced Care Management (ECM) program. This role supports members with chronic health conditions, behavioral health needs, substance use disorders, homelessness, or frequent hospitalizations by coordinating care, closing gaps in services, and connecting members to clinical and community-based resources. The ECM Case Manager (LVN) works cross-functionally with internal teams, community-based organizations, and health plan partners to improve health outcomes, reduce health disparities, and support continuity of care, directly advancing the ECM program's quality, compliance, and member engagement goals.

Caseload Management & Member Engagement

• Manage an assigned caseload of members with complex medical, behavioral, and social needs across multiple health plan contracts
• Conduct outreach for members regardless of case assignment and regardless of any health plan to support team goals for ECM program engagement
• Meet with members in person including home visits, provider office visits, and community-based settings to build trust, complete assessments, review care plans, and support engagement for members who are difficult to reach telephonically and potentially prospective members
• Support ECM program engagement through member outreach beyond individual caseload assignments as needed to meet team goals

Assessment, Care Planning & Documentation

• Conduct member outreach and complete initial comprehensive assessments, care plans, and interdisciplinary team conferences within specified timeframes set by ECM leadership team
• Develop member-centered care plans with clear, measurable, and achievable goals (e.g., SMART goals), reviewing and updating goals regularly to reflect member progress
• Support the RN Care Manager with clinical assessments, including comprehensive health assessments, medication reconciliation, post-hospital discharge assessments, and standardized screening tools (e.g., PHQ-9, GAD-7, Edinburgh Postnatal Depression Scale)
• Maintain accurate and timely documentation across case management software, Excel trackers, Monday.com boards, and health plan portals

Care Coordination & Team Collaboration

• Coordinate transitions of care, including post-hospital and skilled nursing facility follow-up
• Communicate proactively with PCPs, specialists, behavioral health providers, hospitals, and community-based organizations to close the loop on referrals and prevent gaps in care during transitions
• Review claims and authorizations and perform medication reconciliation in support of care coordination
• Responsible for team-based approach working with both internal and external partners to support ECM program success
• Responsible for individual caseload in addition to supporting ECM members for all contracted health plans

Member Support Services

• Connect members to social services, transportation, housing, food, and other community resources
• Apply motivational interviewing, trauma-informed care, and harm-reduction approaches to support member engagement
• Identify barriers to treatment adherence and adjust care plans accordingly
• Educate members and caregivers on disease management and healthcare navigation

Quality & Compliance

• Monitor member progress and manage caseload activity on a weekly cadence, ensuring deliverables and outcomes are met
• Participate in audits, quality reviews, and team meetings as required
• Maintain accurate and honest timekeeping
• Support fellow care managers by sharing best practices and contributing to a positive, accountable team culture
• Other duties as assigned

Qualifications

• Associate's or Bachelor's degree in a health or human servicesrelated field preferred; equivalent combination of education and progressively responsible clinical experience will be considered
• At least 2 years of clinical experience, such as skilled nursing facility, home health, hospice, case management, or care coordination
• Current, active, and unrestricted Licensed Vocational Nurse (LVN) license in the State of California is required

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at View email address on click.appcast.io to request an accommodation.