We are seeking a compassionate, organized, and patient-centered Ambulatory Case Manager (LVN) to join our outpatient care management team. The Ambulatory Case Manager is responsible for coordinating care for patients with chronic, complex, or high-risk medical conditions across the continuum of care. This role partners with providers, patients, caregivers, health plans, and community resources to improve clinical outcomes, enhance the patient experience, reduce unnecessary emergency department visits and hospitalizations, and support value-based care initiatives. Essential Responsibilities Conduct comprehensive patient assessments to identify medical, psychosocial, and care coordination needs. Develop, implement, and monitor individualized care plans in collaboration with patients, providers, and interdisciplinary team members. Coordinate transitions of care following emergency department visits, hospital admissions, and discharges. Provide telephonic and in-person care management, patient education, and self-management coaching. Monitor patients with chronic diseases and complex medical conditions to improve adherence to treatment plans. Facilitate referrals to specialists, behavioral health providers, home health agencies, social services, and community resources. Collaborate with primary care providers, specialists, social workers, and other healthcare professionals to ensure coordinated, high-quality care. Identify and address barriers to care, including transportation, financial concerns, medication access, and social determinants of health. Document all patient interactions and care plans accurately and timely in the electronic health record. Maintain compliance with organizational policies, regulatory requirements, and payer guidelines. Minimum Qualifications Current, unrestricted LVN license. Minimum of two years of clinical nursing experience. At least one year of case management, care coordination, ambulatory, managed care, population health, or chronic disease management experience preferred. Strong knowledge of care coordination, transitions of care, utilization management, and community resources. Excellent communication, organizational, and critical thinking skills. Why Join Us? Join a team dedicated to improving the health of our community through coordinated, patient-centered care. You'll have the opportunity to build meaningful relationships with patients, collaborate with an interdisciplinary care team, and make a measurable impact on quality outcomes and patient satisfaction.
Job Type:
Full-time Pay:
From $34.00 per hour
Benefits:
401(k) Dental insurance Health insurance Paid sick time Paid time off Vision insurance
