Licensed Vocational Nurse (LVN) - ECM Department

Job Summary Under the general supervision of the ECM Program Director, the Licensed Vocational Nurse (LVN) is responsible for providing high-quality care coordination and support services to Enhanced Care Management (ECM) members with complex medical and psychosocial needs. The LVN collaborates closely with ECM team members, primary care providers, specialists, community partners, caregivers, and members to promote whole-person care, improve health outcomes, and ensure timely access to appropriate medical, behavioral health, and community-based services. The LVN serves as an integral member of the interdisciplinary ECM team by assisting with outreach and engagement activities, health education, care coordination, transition planning, member advocacy, and resource linkage services. The LVN utilizes member-centered and evidence-based communication techniques, including Motivational Interviewing, to support members in achieving their health goals and improving self-management skills. Duties And Responsibilities Care Management and Member Support Manage and coordinate care for a designated caseload of ECM members with complex medical, behavioral, and social needs. Conduct outreach, engagement, and follow-up activities to establish and maintain meaningful relationships with ECM members and their support systems. Assist members in understanding and managing their health conditions, prescribed treatments, medications, and preventive care needs within the LVN scope of practice. Utilize evidence-based approaches, such as Motivational Interviewing, to support member engagement, self-management, and positive health behaviors. Provide health education and coaching regarding chronic disease management, treatment plans, medication adherence, and wellness strategies. Care Coordination Support the completion of Comprehensive Health Assessments (CHA) and contribute relevant clinical information within the LVN scope of practice. Collaborate with ECM team members in developing, implementing, and updating Shared Care Plans (SCP) and Health Action Plans (HAP). Communicate care plan goals, interventions, and progress with members, caregivers, providers, and interdisciplinary team members. Coordinate services among primary care providers, specialists, hospitals, skilled nursing facilities, behavioral health providers, home health agencies, and community organizations. Assist members with scheduling appointments, obtaining referrals, accessing transportation resources, and navigating healthcare and social service systems. Participate in transition-of-care activities, including post-hospitalization and post-emergency department follow-up to reduce gaps in care and prevent readmissions. Identify barriers to care and collaborate with team members to develop solutions that address social determinants of health. Collaboration and Team Participation Work collaboratively with ECM team members, providers, community partners, caregivers, and family members to ensure coordinated and integrated care. Participate in interdisciplinary case conferences, team meetings, and systematic case reviews to discuss member progress and care planning. Consult with Nurse Care Managers, Behavioral Health Care Managers, and other licensed professionals regarding clinical concerns and member care needs. Represent the ECM program professionally during interactions with members, providers, and community partners. Documentation and Compliance Maintain accurate, timely, and complete documentation in the electronic health record and other required systems in accordance with regulatory, contractual, and organizational requirements. Ensure all member interactions, assessments, interventions, and care coordination activities are documented appropriately. Protect the privacy and confidentiality of member information in accordance with HIPAA regulations and organizational policies. Participate in audits, quality assurance reviews, and performance improvement activities as required. Quality Improvement and Professional Development Support quality improvement initiatives designed to enhance member outcomes, operational efficiency, and program effectiveness. Participate in required trainings, staff meetings, committee meetings, and continuing education activities. Maintain current professional licensure and competencies required for the position. Perform other duties and responsibilities as assigned to support ECM program operations and organizational goals. #J-18808-Ljbffr Via Care Community Health Center