Licensed Vocational Nurse - Case Manager

The Licensed Vocational Nurse (LVN) – Case Manager is a key member of Central Health's care coordination team, providing case management and navigation support to assigned patients. Under the supervision of the assigned Nurse Manager, the LVN Case Manager collaborates with RN Case Managers, Social Workers, Community Health Workers, Physicians, and Advanced Practice Providers to support patients through care transitions, ongoing followup, and connection to community resources. This position models a commitment to Central Health's vision, mission, and values and demonstrates compassion, cultural humility, and a dedication to health equity for all patients served.

• Assist RN Case Managers in coordinating care for assigned patients across the care continuum including inpatient, post-acute, ambulatory, and community-based settings.
• Act as a liaison between patients, caregivers, physicians, and external partners to facilitate ongoing care coordination.
• Support the development, implementation, and monitoring of individualized patient care plans under RN oversight.
• Conduct patient outreach and follow-up to monitor status, medication adherence, appointment compliance, and progress toward care plan goals.
• Manage referrals by pre-screening for appropriateness, initiating within scope, scheduling services, and verifying timely completion and follow-up.
• Support care transitions and discharge planning by communicating patient needs and relevant clinical and social information to receiving care teams and partners.
• Identify and report changes in patient condition or social circumstances to the supervising RN or care team promptly.
• Assist with medication management, DME coordination, and benefits and community resource navigation.
• May perform home visits and clinic accompaniments to support care coordination, patient advocacy, and education as assigned.
• Participate in care conferences, rounding, and discharge planning meetings with the interdisciplinary team as assigned.
• Document all patient interactions, care coordination activities, and follow-up actions accurately and timely in the EHR per program and department guidelines.
• Maintain complete and current patient records including care plans, referral tracking, reports, and required forms within established timeframes.
• Maintain compliance with HIPAA, Joint Commission standards, Texas Board of Nursing LVN Practice Act requirements, and Central Health policies and protocols.
• Complete all required orientation, competency validation, and annual training on schedule.
• Communicate clearly and compassionately with patients and families regarding care plans, health education, follow-up expectations, and available resources.
• Provide health education and promote self-management skills to support improved health outcomes and independence under RN or provider direction.
• Apply trauma-informed care principles and cultural humility when engaging patients with complex social needs including homelessness, behavioral health challenges, or substance use disorders.
• Participate actively in interdisciplinary huddles, care conferences, team meetings, and education offerings as required.
• Collaborate with RN Case Managers, Social Workers, Community Health Workers, Physicians, and APPs to ensure seamless, coordinated patient care.
• Maintain strong working relationships with external partners and contribute to a positive, inclusive team culture aligned with Central Health's Nursing Core Values.
• Support new employee orientation and training, meet defined productivity standards, and participate in continuous quality improvement initiatives.
• Performs other duties as assigned.

• Knowledge of LVN scope of practice under Texas Board of Nursing standards as applicable to a care coordination and case management role.
• Understanding of care coordination, case management principles, discharge planning, and care transitions across the continuum of care.
• Knowledge of current evidence-based clinical guidelines, quality improvement processes, and healthcare compliance requirements including HIPAA and Joint Commission standards.
• Strong verbal and written communication skills with the ability to convey information clearly and compassionately to patients, families, and interdisciplinary team members.
• Demonstrated ability to work effectively under RN supervision, manage an active caseload, prioritize multiple activities simultaneously, and meet documentation deadlines.
• Ability to apply critical thinking to identify patient needs, barriers to care, and opportunities for intervention, and escalate to the RN as appropriate.
• High level of skill at building professional relationships and delivering excellent, inclusive, patientcentered service across diverse populations with demonstrated cultural humility.
• Commitment to health equity, diversity and inclusion, and Central Health's mission to serve the community.
• Proficiency with electronic health record systems and standard office technology; Epic experience preferred.
• Proficiency in medical record review, data abstraction, and accurate documentation in accordance with program and department guidelines.

Postsecondary Vocational Award (higher degree accepted) Completion of Vocational Nursing Program - Required

2 years Experience with care coordination, patient navigation,discharge planning, or case management activities -Preferred 2 years Experience working with patients with complex chronic disease, behavioral health, or social needs- Preferred

Driver’s License Valid Texas Driver’s License Upon Hire -Required