LVN Case Manager: Care Coordination & Transitions

ACTalent; California; On-site; USD 70,000 - 90,000; Full time

Job summary

ACTalent is seeking a Case Manager in California to coordinate care for members with complex medical needs. The role involves outreach, assessment, care planning, and follow-up while collaborating with providers, internal teams, and community resources.

Responsibilities include prioritizing cases, managing a caseload, conducting follow-ups in multiple settings, and ensuring timely documentation and discharge transitions. Strong LVN credentials and acute care experience are required.

Qualifications

• Graduate of an accredited Licensed Vocational Nursing (LVN) program.
• Current LVN license in good standing.
• Minimum of 2 years of clinical nursing experience, or at least 1 year of case management experience.
• Experience in acute care or hospital settings.
• Knowledge of medical terminology and clinical documentation standards.
• Ability to perform comprehensive assessments and develop individualized plans of care.
• Proficiency using Microsoft Office applications, including Word, Outlook, Excel, and PowerPoint.
• Ability to work effectively with electronic medical/health records (EMR/EHR) and related software.
• Strong organizational skills with the ability to manage a caseload and meet established timeframes.
• Effective verbal and written communication skills for interacting with members, providers, and colleagues.
• Ability to work independently and as part of an interdi

Responsibilities

• Identify complex cases based on established enrollment criteria and prioritize members for case management services.
• Monitor and manage an assigned member caseload, performing routine follow-ups with each patient to assess progress and needs.
• Conduct patient follow-ups telephonically, in the primary care provider's office, in the patient's home, or in other appropriate settings based on the patient's condition and needs.
• Contact members after hospital discharge and after completion of the transitional nurse visit to discuss program details, offer enrollment, and initiate the enrollment process.
• Ensure all documentation of member interactions, assessments, and interventions is thorough, accurate, and completed within established timeframes.
• Document actions taken to prevent hospital readmission and other transitions of care, ensuring clear rationale and outcomes are recorded.
• Complete required Health Risk Assessment (HRA) outreach within 30 days of member eligibility or upload from the health plan.
• Develop individualized plans of care with goals that are Specific, Measurable, Attainable, Realistic, and Time Bound (S.M.A.R.T.), reflecting each member's unique needs and priorities.
• Submit care plans to the registered nurse for review and approval, and update the plan of care as members' health conditions and needs change.
• Upload pertinent medical records and documents to the member's electronic medical/health record (EMR/EHR) to ensure accurate and up-to-date information.
• Collaborate with healthcare providers and staff involved in the member's care to optimize continuity of care, minimize unnecessary resource utilization, reduce hospitalizations, and support member adherence to treatment plans.
• Educate members on available organizational resources and community services, helping them understand and access appropriate support.
• Mail welcome packets to members, including resource booklet information and other relevant program materials.
• Obtain updated orders from primary care providers or other applicable healthcare providers to initiate services not included in the initial discharge plan.
• Submit all orders with pertinent supporting documentation to the case management support team for timely submission to providers' offices before or at the time of patient appointments.
• Attend care coordination interdisciplinary team (IDT) meetings and staff meetings to discuss cases, share updates, and support collaborative care planning.
• Collaborate with the scheduling team to ensure members receive timely and appropriate appointments and services.
• Assist with processing referrals to expedite care, optimize health outcomes, and prevent exacerbation of disease processes.
• Submit shared drive communication forms and advance directives to the appropriate staff in accordance with departmental policies and procedures.
• Stay current with hospital discharge planning expectations and interventions, ensuring outreach and follow-up are timely and aligned with departmental standards.
• Maintain professional communication with members, families, providers, and internal teams to support a positive care experience and effective case management.

Skills

Case management

Nursing experience

EMR/EHR proficiency

Microsoft Office

Education

LVN program

LVN license

Tools

EMR/EHR systems

Microsoft Office Suite

Job description

ACTalent is seeking a Case Manager in California to coordinate care for members with complex medical needs. The role involves outreach, assessment, care planning, and follow-up while collaborating with providers, internal teams, and community resources.

Responsibilities include prioritizing cases, managing a caseload, conducting follow-ups in multiple settings, and ensuring timely documentation and discharge transitions. Strong LVN credentials and acute care experience are required.