LVN Chronic Care Management

2 weeks ago

Stockton, United States Community Medical Centers Full time

POSITION SUMMARY:

Under the supervision of the Associate Director of Clinical Programs, the Chronic Care Management Licensed Vocational Nurse (LVN) is responsible for intake and providing ongoing case management services for the medically and/or socially complex patients of Community Medical Centers (CMC). The patient population covered will include significantly complex medical conditions, and/or social-economic and mental health co-morbidities. The goal of the program will be to assist these patients to achieve optimal health and/or independence in managing their care. To achieve this goal the CCM LVN will demonstrate and apply knowledge of the philosophy/principles of comprehensive case management, patient centered, culturally sensitive care coordination and management of complex patients. The primary contact with the patient, family and other involved care providers will be by telephone, and electronic medical record (EMR). In addition, s/he is responsible for creating and sustaining partnerships with community resources and support agencies.

SPECIFIC DUTIES:

* Promotes the mission, vision, and values of Community Medical Centers
* Implements standardized nursing procedures for nurse-delivered, patient-centered care
* Cares for all patients in collaboration with the healthcare team by utilizing skills of motivational interviewing to assist patients in engagement and setting action-oriented self-management goals
* Communicates clearly and effectively by using welcoming words, proper tone of voice, appropriate body language, eye contact and smiling with every interaction.
* Assess the physical, functional, social, psychological, environmental, learning and financial needs of patients.
* Identify problems, goals and interventions designed to meet patient's needs, including prioritized goals that consider the patient/caregivers goals, preferences and desired level of involvement in the case management plan
* Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
* Assess the patient's formal and informal support systems, including caregiver resources and involvement as well as available benefits and/or community resources.
* Implement and monitor the care plan to ensure the effectiveness and appropriateness of services
* Evaluate patient's progress toward goal achievement and effectiveness of plan, including identification and evaluation of barriers to meeting or complying with case management plan of care, and systematically reassess for changes in goals and/or health status.
* Collaborates with primary care physicians and members of the comprehensive care team regarding the status of patient.
* Performs regularly scheduled outbound calls to patients as well as contact for patients who were recently discharged from acute hospitalizations and who are considered a high risk of readmission
* Maintain accurate patient records and patient confidentiality
* Engage in professional development activities to keep abreast of case management practices and patient engagement strategies.
* Facilitate disease prevention and health promotion with patients and families
* Assist with the collection, analysis, and benchmarking of utilization data.
* Collaborate in the development of protocols and guidelines for patient care management
* Committees and taskforces
* Outreach activities
* Nursing and staff meetings
* Training and continuing education activities
* Delegates appropriate tasks to unlicensed staff according to their scope of practice
* Provides feedback to Associate Director of Clinical Programs for employee performance evaluations and corrective actions when needed
* Assists other clinicians as needed
* Performs skilled nursing care and provides patient education within scope of practice as established by the California LVN Board and CMC policies
* Adheres to the flexible work policy
* Performs other duties as required

Qualifications

MINIMUM REQUIREMENTS:

* Current licensure as a Licensed Vocational Nurse in the state of California
* Proficient with Microsoft Office computer applications
* Proficient using an Electronic Health Records system/s
* Next Gen and/or Epic EHR experience is preferred
* Ability to travel between sites as needed
* Valid California Driver's License, proof of auto insurance, and personal transportation
* Experience in an ambulatory care nursing and chronic care management desired
* Current certification in basic life support (BLS)

KNOWLEDGE, SKILLS, AND ABILITIES:

* Work in a Care Team environment that is flexible, innovative and focuses on results
* Act professionally while representing CMC at both internal and external events
* Identify and promote best practices in patient care while abiding by organizational policies, regulations, and procedures to administer and document patient care
* Handle multiple priorities in the performance of nursing duties
* Ability to listen skillfully and display a willingness and ability to acknowledge the needs, expectations, and values of others using reflective listening and empathy conveyance. Responds to needs in ways that are helpful and beyond expectation.
* Ability to provide excellent customer service that is reflective of a culture that values trust and respect
* Knowledge and skill in chronic disease management
* Ability to promote/participate in patient centered medical home mode of care
* Exceptional customer service skills and understanding of patient and family centered care concepts

TYPICAL PHYSICAL DEMANDS:

Requires full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extensive periods of time. Occasionally lifts and carries items weighing up to 50 pounds. Requires corrected vision and hearing to normal range. Requires working under stressful conditions or working irregular hours.

TYPICAL WORKING CONDITIONS:

Work is performed in an office environment within a clinic setting. Involves frequent contact with staff and the public. Work may be stressful at times. Contact may involve dealing with upset people.

Community Medical Centers is an Equal Opportunity Employer. It is CMC's policy to provide equal employment opportunities to all persons, regardless of age, race, religion, color, national origin, sex, political affiliations, marital status, non-disqualifying physical or mental disability, sexual orientation, membership, or non-membership in an employee organization or on the basis of personal favoritism or other non-merit factors except where otherwise provided by law.

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