Licensed Vocational Nurse

Licensed Vocational Nurse (LVN) - Chronic Care Management (CCM) Position Summary The Licensed Vocational Nurse (LVN) supports the Chronic Care Management (CCM) 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 (RNs), Medical Assistants (MAs), 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 (EMR). Essential Duties & Responsibilities 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. Qualifications Required Current California Licensed Vocational Nurse (LVN) license in good standing. Minimum one (1) year of clinical experience in ambulatory care, case management, primary care, population health, or chronic disease management preferred. 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. 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. Epic and eCW EMR experience preferred. Bilingual preferred but not required. Core Competencies Compassionate patient-centered communication Critical thinking and problem-solving Attention to detail and documentation accuracy Strong follow-through and accountability Ability to prioritize and manage a high-volume workload Team collaboration and adaptability Physical Requirements Prolonged sitting, standing, and computer use. Ability to communicate effectively by phone, email and Microsoft Teams. Work Environment Remote position Frequent telephone and computer-based patient interaction. Fast-paced enviornment requiring multitasking and adaptability. Reports To Director of Medical Management Mon - Fri (7 am - 5 pm)