LPN - Remote - Primary Care

MUST HAVE A VALID CA LICENSE VOCATIONAL NURSE (LVN) LICENSE Coordinate with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services.
Engage eligible members.
Oversee provision of ECM services and implementation of the care plan.
Offer services where the member lives, seeks care, or finds most easily accessible and within the Plan guidelines.
Connect member to other social services and supports the member may need, including transportation.
Advocate on behalf of members with health care professionals.
Use motivational interviewing, trauma-informed care, and harm-reduction approaches.
Coordinate with hospital staff on discharge plans.
Accompany member to office visits, as needed and according to the Plan guidelines.
Monitor treatment adherence (including medication).
Provide health promotion and self-management training
Promote timely access to appropriate care
Increase utilization of preventative care
Reduce emergency room utilization and hospital readmissions
Increase comprehension through cultural and linguistically appropriate education
Create and promote adherence to a care plan, developed in coordination with the member, primary care provider, and family/caregiver(s)
Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
Increase members’ ability for self-management and shared decision-making
Connect members to relevant community resources to enhance member health and well-being, increase member satisfaction, and reduce health care costs.
Connect and follow up with members, family/caregiver(s), providers, and community resources via face-to-face, secure email, phone calls, text messages, and other communications.
Serve as the contact point, advocate, and informational resource for members, care team, family/caregiver(s), payers, and community resources
Work with members to plan and monitor care
Assess member’s unmet health and social needs
Develop a care plan with the member, family/caregiver(s), and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
Monitor adherence to care plans, evaluate effectiveness, monitor member progress on time, and facilitate changes as needed
Create ongoing processes for members and family/caregiver(s) to determine and request the level of care coordination support they desire at any given time.
Facilitate member access to appropriate medical and specialty providers
Educate members and family/caregiver(s) about relevant community resources
Facilitate and attend meetings between members, family/caregiver(s), care team, payers, and community resources, as needed
Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
Assist with the identification of “high-risk” members (the chronically ill and those with special health care needs), and add these to the member registry (or flag in EHR)
Attend all Lead Care Manager training courses/webinars and meetings
Provide feedback for the improvement of the ECM Program
Offer services where the Member lives, seeks care, or finds most easily accessible and within Medi-Cal Managed Care health plans (MCP) guidelines
Arrange transportation
Call Members to coordinate visitation with them at their home, or in the hospital, as needed
QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below represent the required knowledge, skill, and/or ability. Reasonable accommodations may enable individuals with disabilities to perform essential functions.
Although this role is remote, there will be times when you will be required to report to our satellite office (or a specified, remote location) to work, to attend meetings, or other training
Required to have and maintain a reliable means of transportation for this role
You will receive a monthly mileage reimbursement per applicable state/federal laws
You must have a valid driver’s license, proof of insurance, and a good driving record
You will visit hospitals and visit patients at their homes, as needed
Must present proof of Negative TB Test & BLS/CPR certification before hire date
Must complete a Live Scan Fingerprint/Background check
EDUCATION AND/OR EXPERIENCE: Current LVN licensure in the State of California
Proficiency in communication technologies (email, cell phone, etc.)
Highly organized with the ability to keep accurate notes and records
Experience with Health IT systems and reports is desirable
Local knowledge about and connections to community health care and
social welfare resources are desirable
SKILL AND KNOWLEDGE REQUIREMENTS: Bi-lingual (Chinese, Mandarin, Spanish) a PLUS!
Excellent analytical, problem-solving, and prioritization skills
Use statistical and graphic displays
Excellent verbal and written communication skills
High-level interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and diverse teams that may include employees, customers, and physicians
Effective computer skills, particularly Microsoft Office, Excel, PowerPoint, Word, etc.
Work independently to complete assigned tasks
Team building
Project Management
Change Management
Quality and Process improvement tools
Project Execution
MUST consistently achieve a minimum daily expectation of 30 schedules/day
BENEFITS: Available after successful completion of the 90-day probationary period
Free Life Insurance
401k eligibility after 1,000 hours of service

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