License Vocational Nurse-Lcm; Los Angeles-Inglewood Area

MUST HAVE A VALID CA LICENSE VOCATIONAL NURSE (LVN) LICENSE

The Lead Care Manager (LVN) works in collaboration and continuous partnership with chronically ill or “high-risk” members and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:

• 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.

• 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…