LPN Case Manager

The Licensed Vocational Nurse (LVN/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 by coordinating appointments, monitoring biometric data, providing patient education, conducting home visits, and connecting patients with community resources. This role requires strong communication and documentation skills, the ability to work independently, and flexibility. The LPN is part of a multidisciplinary care team and manages a rolling caseload of approximately 25 30 patients while traveling to various patient and provider locations as needed. Responsibilities:

• Assist RN Care Manager with implementation of patient care plans.
• Schedule patient appointments and monitor biometric data.
• Provide and reinforce patient education regarding care and medications.
• Attend patient visits and complete home visits as required.
• Connect patients with appropriate community resources and support services.
• Maintain frequent contact with patients to monitor progress and adherence.
• Document patient interactions and care activities accurately in the electronic health record (EHR).
• Participate in multidisciplinary care team rounds to provide patient updates.
• Manage a monthly rolling caseload of approximately 25 30 patients.
• Work collaboratively with social workers, pharmacists, and other care team members.
• Travel to patient homes, hospitals, and provider offices as necessary.

• Current Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) licensure in the state of practice.
• Basic Life Support (BLS) certification.
• Minimum of 1 year of nursing experience, preferably in home health, case management, or related settings.
• Strong clinical knowledge, especially related to CHF, COPD, and complex comorbidities.
• Excellent verbal and written communication skills.
• Ability to work independently and manage a caseload effectively.
• Proficiency in electronic health record (EHR) documentation.
• Access to reliable transportation for travel to patient and provider locations.

• Experience with care coordination and community resource linkage.
• Familiarity with transitions of care programs and reducing hospital readmissions.
• Experience working in multidisciplinary care teams.
• Knowledge of remote patient monitoring and telephonic follow-ups.

• This is not a hands-on nursing role; focus is on care coordination and patient education.
• Mobile position requiring travel to patient homes, hospitals, and provider offices within the region.
• Must be able to remain flexible throughout the workday to accommodate patient and team needs.
• Responsible for managing a caseload of 25 30 patients monthly.

• Full-time position, Monday through Friday, 8:00 a.m. to 4:30 p.m.
• 40 hours per week guaranteed.
• Work primarily remote/mobile with scheduled visits to various locations as required.