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LVN Case Management - Bakersfield, United States - Heritage Provider Network
Description
Job Description
Under the direction of theSupervisor, this position is responsible toassess, diagnose, plan, implement, and evaluate the patient to facilitate and coordinate the patient's plan of care with the provider.
The Case Manager will help determine when patients are stable for discharge from Priority Care back to their home (i.e., residence, Assisted Living Facility, LTC placement) with medical follow-up by a physician.
The Case Manager in addition may be given members to be assessed and managed in the SNP Program (Special Needs Population).
The LVN Priority Care Case Manager will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.
1.1 Be flexible and adaptable.1.2 Obtain and document all pertinent patient information and notes in NextGen.
1.3 Strive for a positive and professional relationship with providers, patients, and families.
1.4 Provide effective communication with various health care providers, including specialists.
1.5 Attend all scheduled patient office visits in the Priority Care Clinic and execute provider orders in a timely manner.
1.7 Level 1A- HIGH acuity- Weekly Case Manager follow up: end stage health conditions, severe, acute and/or chronic health concerns.
1.9 Level 2A- LOW acuity- Monthly Case Manager follow up: stable, needs minimal follow up, conditions well controlled, near return to PCP.
1.11 Complete annual comprehensive assessment with RN reviewing LVN documentation. Assessment must be initiatedwithin 30 days from the referral date and completed within 60 days.
1.12 Comprehensive assessment to include patient's clinical history, self-reported health status and goal, care plans with goals and Barriers with progress towards goals, medication reconciliation, social history, caregiver resources, hearing and vision, available benefits, community resources, interdisciplinary care team members, next scheduled Case Manager follow up, health screenings, life planning activities, assessment summary an conclusion.
1.13 Create a comprehensive and working care plan following NCQA, CMS, and Health Plan guidelines with input from the interdisciplinary care team and patient or caregiver.
1.15 Incorporate the completed HRA (Health Risk Assessment), provided by the Health Plan, into the care plan.
1.16 Update care plans with changes in patient's medical status.
1.17 Be knowledgeable regarding disease processes, labs, and medications to ensure the ability to assess patient needs and provide education as indicated.
1.18 Coordinate the provision of Social Services and/or Patient Services Coordinator to patients and families to enable them to cope with the impact of illness on individual family functioning and to achieve maximum benefits from health care services.
1.19 Mobilizes resources and intervenes as needed to achieve expected goals to assist in achieving desired clinical outcomes within the desired timeframe.
1.21 Strive for timely admissions and discharges from Priority Care.
1.22 Ensure a smooth transition of care back to Primary Care Provider after discharge from Priority Care.
1.23 Initiate/participate in Code Red, Code White and Code Blue situations as directed.
1.24 Familiarity with the clinical structure of BFMC and health care services with which it contracts.
1.25 Understand patient healthcare benefits and help establish expectations for services within those benefit limits.
1.26 Be familiar with all policies, procedures and documentation related to SNP Program.
1.27 Ensure reporting (annually and/or transitions of care) for SNP patients in IDT meetings.
1.28 Educate and assist in decisions regarding end of life care including advance directive forms, durable power of attorney,POLST forms, etc.
1.30 Participate in Utilization Review process regarding any assigned patients ensuring proper hand off report to UR Case Manager.
1.31 Proficient in computer literacy including typing skills.
1.32 Proficient in Microsoft Word and Microsoft Excel.
Requirements
8.1 Graduation from an accredited Licensed Vocational Nursing program.
8.2 Current California LVN license.
8.3 Current BLS certification.
8.4 Minimum of two years clinical nursing experience.
8.5 Knowledge of Microsoft Office programs.
The pay range for this position at commencement of employment is expected to be between $29.33 and $34.50 however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.
If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.