LVN Case Manager PHM- Bakersfield

Description

Location: Bakersfield, CA (Onsite)

Classification: Full-Time

Schedule: Monday-Friday 8am-5pm

This position is non-exempt and will be paid on an hourly basis.

• Medical
• Dental
• Vision
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

The initial pay range for this position upon commencement of employment is projected to fall between $32.00 and $39.99. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

The LVN Nurse Case Manager provides direct case management support to members across the Population Health Management (PHM) continuum, serving individuals with needs ranging from low-risk preventive care to complex case management. The LVN collaborates with the interdisciplinary care team to deliver enhanced care coordination, assist with individualized care plan development, monitor clinical and social service interventions, and support member engagement in self-management goals.

This position focuses on addressing medical, behavioral health, and social determinants of health needs to improve outcomes, reduce avoidable utilization, and enhance the member experience. The position may also require assignment at a designated clinic site, where the LVN will provide case management services in collaboration with the care team, providers, and members.

• Effectively manage and maintain a caseload of assigned members, ranging from low-risk preventive outreach to members with complex medical and social needs.
• Conduct comprehensive assessments to develop individualized, person-centered care plans in collaboration with the member, caregiver(s), and care team.
• Ensure care plans incorporate physical health, behavioral health, substance use disorder, LTSS, palliative care, community services, housing, and other identified needs.
• Provide culturally appropriate and accessible communication with members through telephonic, virtual, and in-person outreach. Case managers may also attend critical appointments with members to support care plan execution and address barriers to engagement. Reassess members at a frequency appropriate for their risk level, progress, or changes in needs, ensuring care plans are updated under appropriate clinical oversight.
• Coordinate services necessary to implement the care plan, ensuring continuity and integration of care across primary care, specialists, behavioral health, pharmacy, and community-based providers.
• Organize and participate in Interdisciplinary Care Team (ICT) meetings to review member care plans, update progress, and ensure member-centered care.
• Provide education, coaching, and motivational interviewing to encourage lifestyle changes and support effective self-management skills.
• Support member engagement by coordinating medication review and/or reconciliation, scheduling appointments, providing reminders, arranging transportation, accompanying members to critical appointments, and addressing barriers to engagement.
• Deliver transitional care services, including discharge risk assessments, post-discharge follow-up, medication reconciliation, contingency planning, and coordination of post discharge services (home health, DME, transportation, prescriptions, follow-up visits).
• Ensure closed-loop referrals to community supports, housing, and social service agencies, with follow-up to confirm services were delivered, including authorizations issued by the organization for care services.
• Monitor member conditions, health status, medications, and care planning on an ongoing basis, escalating changes to the RN Case Manager or clinical leadership as appropriate.
• Support quality improvement by helping close HEDIS, MCAS, STARs, and SNP MOC gaps in care.
• Accurately and timely document all case management activities in…