Licensed Vocational Nurse (LVN) - ECM

Position Summary

The Licensed Vocational Nurse (LVN) serves as a vital member of the Enhanced Care Management (ECM) team, supporting high-risk Medi-Cal members with complex medical, behavioral health, and social needs throughout Hiring County. Working under the supervision of the Registered Nurse Clinical Case Consultant, the LVN assists with care coordination, member assessments, health education, medication reconciliation, transitions of care, chronic disease management, outreach, and clinical documentation.

Essential Duties and Responsibilities

Clinical Care Coordination

• Support care coordination activities for members enrolled in the CalAIM Enhanced Care Management (ECM) program.
• Assist members in understanding treatment plans, discharge instructions, medications, and provider recommendations.
• Conduct clinical outreach to members, caregivers, providers, hospitals, and health plans.
• Monitor member progress and communicate clinical concerns to the Registered Nurse Clinical Case Consultant.
• Assist in identifying barriers to care and developing solutions that support member success.
• Support continuity of care and transitions following hospitalizations, emergency department visits, and other healthcare events.
• Assist with coordination of specialty care, behavioral health services, and community-based resources.

Member Assessments & Clinical Support

• Conduct health screenings and assessments within LVN scope of practice.
• Collect and document health information, vital signs, medication information, and clinical observations.
• Assist with chronic disease management support for conditions such as diabetes, hypertension, COPD, heart disease, and other chronic illnesses.
• Monitor member symptoms and escalate concerns appropriately.
• Provide health education regarding disease management, medication adherence, preventive care, and wellness strategies.

Medication Management Support

• Perform medication reconciliation activities under RN supervision.
• Educate members regarding prescribed medications and treatment plans.
• Monitor medication adherence and identify barriers to compliance.
• Communicate medication concerns to the RN, providers, and care team members.
• Assist in coordinating medication-related resources and services.

Community Outreach & Member Engagement

• Conduct community-based outreach activities throughout Hiring County to identify, engage, and support eligible members.
• Participate in outreach events, health fairs, community resource events, and networking opportunities.
• Collaborate with healthcare providers, hospitals, skilled nursing facilities, shelters, behavioral health programs, and community-based organizations to identify members who may benefit from ECM services.
• Assist with member enrollment efforts and program education.
• Build and maintain professional relationships with referral sources and community partners.
• Promote awareness of Pacific Health Group's ECM, Community Supports, and Behavioral Health programs.

Field-Based Member Support

• Conduct in-home, community-based, and provider-site visits with members as assigned.
• Accompany Lead Care Managers, Community Health Workers, and Registered Nurses during field visits when clinical support is needed.
• Participate in joint visits with providers, health plans, hospitals, and community partners.
• Support member engagement efforts and strengthen relationships with hard-to-reach populations.
• Ensure member safety and report concerns according to organizational protocols.

Collaboration & Interdisciplinary Team Support

• Collaborate with Registered Nurses, Lead Care Managers, Community Health Workers, Behavioral Health staff, providers, health plans, and community organizations.
• Participate in interdisciplinary team meetings, case conferences, and care planning activities.
• Provide clinical input regarding member needs, risks, and care coordination strategies.
• Support integrated care delivery and whole-person care initiatives.

Documentation & Compliance

• Maintain timely, accurate, and complete documentation in the electronic health record and care management systems.
• Ensure documentation complies with Medi-Cal, CalAIM ECM, organizational, and regulatory requirements.
• Participate in quality assurance and audit readiness activities.
• Protect member confidentiality and maintain HIPAA compliance at all times.

Quality Improvement & Professional Development

• Participate in quality improvement initiatives and workflow enhancement projects.
• Attend required training, meetings, and professional development opportunities.
• Maintain current licensure and required certifications.
• Support organizational initiatives focused on improving member outcomes and service delivery.

Minimum Qualifications

• Current and unrestricted California Licensed Vocational Nurse (LVN) license.
• Minimum one (1) year of clinical experience in healthcare, managed care, home health, public health, behavioral health, post-acute care, or community health settings.
• Strong understanding of care coordination and chronic disease management principles.
• Excellent communication, organizational, and interpersonal skills.
• Ability to work independently and collaboratively within interdisciplinary teams.
• Basic proficiency with electronic health records and Microsoft Office applications.
• Must reside in or within a reasonable commuting distance of Hiring County.
• Valid California Driver's License (Class C minimum).
• Reliable transportation and current automobile insurance meeting California minimum requirements.
• Ability to successfully pass a Motor Vehicle Report (MVR) review.

Preferred Qualifications

• Experience with CalAIM Enhanced Care Management (ECM), Whole Person Care (WPC), Health Homes Program (HHP), or similar care management programs.
• Experience working with Medi-Cal populations.
• Experience supporting individuals experiencing homelessness, serious mental illness, substance use disorders, justice involvement, or multiple chronic conditions.
• Bilingual in Spanish, Vietnamese, Tagalog, Punjabi, Hmong, or other languages commonly spoken within Hiring County communities.
• Community-based healthcare experience.

Work Environment & Travel Requirements

This is a hybrid position requiring a combination of remote work, office-based work, and field-based activities. Frequent travel throughout Hiring County is required to conduct member visits, participate in community outreach activities, attend provider meetings, support care coordination efforts, and collaborate with community partners. Must be willing to work occasional evenings and weekends as needed.