Licensed Vocational Nurse- Chronic Care Management

The intent of this job description is to provide a summary of the major duties and responsibilities performed in this job. Incumbents may be requested to perform job-related tasks other than those specifically presented in this description.

The Licensed Vocational Nurse supports the Chronic Care Management program by providing ongoing care coordination, patient outreach, education, and clinical support for patients with chronic conditions. This role works collaboratively with providers, Registered Nurses, Medical Assistants, and the Care Management team to improve patient outcomes, support preventive care initiatives, reduce avoidable hospital utilization, and ensure high-quality patient-centered care.

The LVN plays a key role in assisting patients with care plan adherence, transitions of care, medication reconciliation support, appointment coordination, and chronic disease education while maintaining accurate documentation within the electronic medical record.

Essential Job Duties: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Patient Care Coordination

• Conduct outbound and inbound patient outreach for CCM services.
• Assist with enrollment and onboarding of eligible CCM patients.
• Maintain regular monthly patient contact per CCM program requirements.
• Support development and reinforcement of individualized patient care plans.
• Identify patient barriers to care and escalate concerns appropriately.
• Coordinate follow-up appointments, referrals, and community resources as needed.
• Assist with Transitional Care Management (TCM) and post-discharge follow-up workflows when assigned.

Clinical Support

• Review and update patient histories, medications, and chronic condition information.
• Perform medication reconciliation under provider/RN direction and within LVN scope of practice.
• Monitor patient-reported symptoms, vital health concerns, and changes in condition.
• Escalate urgent or clinically significant findings to RN or provider promptly.
• Reinforce care plans and chronic disease education with patients and caregivers.

Documentation & Compliance

• Accurately document all patient interactions and CCM activities in Athena EMR and/or designated tracking systems.
• Ensure documentation supports CCM billing and compliance requirements.
• Maintain confidentiality and comply with HIPAA regulations.
• Participate in quality improvement initiatives and workflow optimization efforts.

Collaboration & Communication

• Collaborate with providers, hospital teams, specialists, home health agencies, SNFs, and community partners to support continuity of care.
• Participate in team huddles, case reviews, and interdisciplinary meetings.
• Communicate professionally and compassionately with patients, families, providers, and staff.
• Assist with patient education and engagement initiatives to improve adherence and outcomes.

Required education and experience: The requirements listed below are representative of the knowledge, skills, and/or ability required.


Minimum Education required:

• Current California Licensed Vocational Nurse (LVN) license in good standing.

Minimum Experience Required:

• Minimum one (1) year of clinical experience in ambulatory care, case management, primary care, population health, or chronic disease management preferred.

Minimum Knowledge and Skills Required:

• Knowledge of chronic disease processes and care coordination principles.
• Strong communication, organizational, and time management skills.
• Ability to work independently while functioning effectively within a team environment.
• Proficiency with EMR systems and Microsoft Office applications. Epic and eCW EMR experience preferred.
• Experience with Chronic Care Management (CCM), Transitional Care Management (TCM), or population health programs.
• Experience working with Medicare, ACO, IPA, or managed care populations.
• Bilingual preferred but not required.

Mon - Fri (7 am - 5 pm)