Nurse Discharge Planner LVN - CalAIM

Job Description

Job Description

Overview

The Nurse Discharge Planner LVN develops and coordinates clinically informed reentry care plans for CalAIM-eligible individuals to address medical, behavioral health, and substance use needs prior to release. The role conducts basic nursing assessments, reviews health records, coordinates referrals, and facilitates warm handoffs to managed care plans and community providers. The position ensures timely service delivery by documenting services in the EHR, tracking release timelines, activating Justice-Involved aid codes, and collaborating with in-reach partners and Medi-Cal eligibility staff.

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.

Qualifications

Education

• Graduation from an accredited School of Nursing is required.
• Bachelor's degree in Social Work, Business Administration, or other health-related fields from an accredited college or university is preferred

Experience

• Previous experience in developing successful transition plans involving community resources for persons with medical, substance use, and/or mental illness is preferred.

Licenses/Certifications

• Have and maintain current licensure as a Licensed Practical/Licensed Vocational Nurse within the state of employment.
• Must maintain CPR certification, and any other certifications (such as First Aid) required by contract.
• Must be able to attain and maintain security clearance to the facility.