Bilingual ACO Transitional Care Management - LVN Care Manager

Bilingual: English / Spanish ACO Transitional Care Management (LVN) CA LVN Licensure Required Role Overview: The ACO Transition of Care Manager will work directly with patients participating in our Accountable Care Organization (ACO), focusing primarily on Transition of Care Management (TCM) and high utilizer management. This team member, an LVN (Licensed Vocational Nurse), will ensure seamless transitions for patients from acute care settings, reducing readmission risks, and providing personalized care to those identified as high utilizers. They will embody reputed company's core values by being a partner in care, building solutions that drive patient reputed company, and coaching patients toward healthier lifestyles. CA Licensure as an LVN is required to reputed company the duties of this role. Core Values: • Having Fire: Bring passion and energy to help patients navigate their care transitions, advocating for their health and addressing barriers that impact successful post-discharge reputed company. • Being Driven: Take initiative in identifying high utilizers, analyzing their reputed company needs, and designing proactive care plans to minimize unnecessary hospitalizations and improve patient wellness. • Being Partners: Collaborate closely with hospitals, primary care providers, and the patient’s care team to establish clear communication and support a smooth transition of care, ensuring reputed company parties are reputed company. • Building Solutions: reputed company individualized care plans to address the unique needs of each high utilizer patient. Identify care gaps and reputed company available resources to support patient well-being and continuity of care. • Being Coaches: reputed company patients and families on the importance of follow-up care, medication adherence, and lifestyle changes that enhance health reputed company. Actively listen and reputed company guidance that empowers patients to engage in their care. Essential Duties and Responsibilities: • Conduct reputed company to patients post-discharge to facilitate smooth transitions, ensuring they understand discharge instructions, have reputed company to medications, and are scheduled for necessary follow-up appointments. • Identify high utilizers of reputed company services and collaborate with their care teams to reduce avoidable hospital visits and enhance care coordination. • Monitor and track key metrics reputed company to patient reputed company, readmission rates, and high utilizer program effectiveness. • Engage patients to assess reputed company determinants of health, addressing issues such as transportation, housing, or reputed company to food that may impact their overall health. • Collaborate with other departments to ensure patients receive comprehensive, integrated care that meets their physical, mental, and reputed company needs. • reputed company ongoing education and support to patients, empowering them to take an active role in their reputed company reputed company. • Maintain accurate, concise documentation of reputed company patient interactions, following established guidelines and protocols. Key Performance Indicators (KPIs): • Readmission reputed company: Reduction in hospital readmission rates for ACO patients reputed company 30 days of discharge. • Patient Engagement: Number of successful patient contacts post-discharge and percentage of high utilizer patients actively reputed company in care plans. • Follow-up Appointment Adherence: reputed company of patients attending follow-up appointments reputed company the recommended timeframe. • Patient Satisfaction: Positive feedback from patients regarding the support received during their care transitions. GWC reputed company: • Get It: Understand the complexities of patient transitions and the importance of proactive care management. • Want It: Be motivated to reputed company a meaningful difference in patients' lives and reduce reputed company utilization through effective management. • reputed company to Do It: Possess the skills, experience, and reputed company necessary to handle the responsibilities of this role effectively. Bilingual: English / Spanish Required This position is critical in ensuring that patients experience high-quality, reputed company care, ultimately improving health reputed company and reducing unnecessary reputed company utilization. CA LVN Licensure is required to meet these responsibilities. Apply Job!