LPN Case Manager

The Licensed Vocational Nurse (LVN) / Licensed Practical Nurse (LPN) Case Manager supports the Transitions of Care program aimed at reducing 30-day hospital readmission rates. Working under the direction of an RN Care Manager, the LPN assists in implementing care plans through appointment scheduling, biometric data monitoring, patient education, home visits, and connecting patients with community resources. This role requires strong communication, documentation skills, and the ability to work independently within a multidisciplinary care team managing a caseload of approximately 25 30 patients. The position involves travel to patient homes, hospitals, and provider offices and is focused on adult and geriatric populations with complex comorbidities. Responsibilities:

• Assist RN Care Manager in implementing patient care plans.
• Schedule patient appointments and monitor biometric data.
• Provide and reinforce patient education on disease management and medication adherence.
• Conduct home visits and attend patient visits as needed.
• Maintain frequent patient contact and document all interactions in the electronic health record (EHR).
• Connect patients with community resources to support care goals.
• Participate in multidisciplinary care team rounds to provide patient updates.
• Manage a monthly caseload of approximately 25 30 patients.
• Support care coordination efforts to reduce hospital readmissions.

• Current and active LPN/LVN license in the state of practice.
• Basic Life Support (BLS) certification.
• Minimum of 1 year of nursing experience, preferably in home health or case management.
• Strong clinical knowledge, especially related to CHF, COPD, and complex comorbidities.
• Excellent communication and documentation skills, including proficiency with EHR systems.
• Reliable transportation and valid driver's license for travel to patient and provider locations.
• Ability to work independently and adapt to a flexible schedule.

• Experience with care coordination and community resource linkage.
• Familiarity with transitions of care programs and reducing hospital readmissions.
• Comfort working within a multidisciplinary care team including social workers and pharmacists.

• This is a mobile position requiring travel to patient homes, hospitals, and provider offices.
• Role is non-hands-on nursing; direct patient care is limited to observation, education, and care coordination.
• Participation in virtual care team rounds is required.
• Must maintain flexibility throughout the workday to accommodate patient and team needs.
• Patient population is adult and geriatric with multiple complex health conditions.

• Full-time position, Monday through Friday, 8:00 a.m. to 4:30 p.m.
• Work schedule is generally consistent with occasional flexibility required for patient visits and care team activities.