LVN-Chronic Case Management

Job Purpose

We are seeking a compassionate and detail-oriented Licensed Vocational Nurse (LVN) licensed in Texas to join our Telephonic Chronic Care Management (CCM) team. In this role, the LVN will provide remote telephonic support to patients with chronic conditions, assisting with care coordination, patient education, and health coaching under the LVN Manager of Value Based Care

In addition, you will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values.

Culture and Values Expectations

At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission “to deliver quality and compassionate care with outstanding service, every patient, every time”. As a (Job Title) at HealthTexas we expect you to embody and promote our Values and defined expectations.

• Integrity: Do the right thing, the right way, every time.
• Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.
• Compassion: Treat everyone with respect and dignity.
• Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.
• Synergy: Collaborate to improve outcomes.
• Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.
• Stewardship: Use resources responsibly and efficiently.
• Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.
  

Essential Job Duties & Responsibilities

• Conduct telephonic outreach to assigned patients enrolled in the CCM program.
• Assist patients in understanding their chronic health conditions and reinforce care plans developed by the provider.
• Document monthly 20 minute non-face-to-face care management interactions as required by CMS.
• Provide health coaching, medication reminders, and assist with scheduling follow-up appointments, referrals, or labs.
• Monitor patient status and communicate significant changes or concerns to the patient’s PCP.
• Help patients overcome barriers to care, such as transportation, medication access, or health literacy.
• Maintain accurate and timely documentation in the electronic health record (EHR).
• Participate in quality improvement initiatives and team meetings.
• Maintain a monthly caseload of 200 patients
• Other duties as assigned.
  
  

Experience

• Minimum 2 years of nursing experience, preferably in chronic disease management, primary care, or telehealth.
• Experience with telephonic nursing, care coordination, or population health is strongly preferred
• Bilingual (Spanish/English) is mandatory.
  
  

Education

• Active LVN license in the state of Texas (unencumbered).
  
  

Knowledge, Skills & Abilities

• Knowledge of chronic conditions such as diabetes, hypertension, COPD, CHF, etc.
• Excellent verbal communication and telephone etiquette.
• Proficient with electronic medical records (EMR/EHR) and Microsoft Office.
• Strong organizational and time-management skills
  
  

Work Hours, Travel Requirements

• Monday – Friday, 8:00 a.m. – 5:00 p.m., and as needed to complete projects.
• Travel to medical offices may be necessary for the purpose of providing education.
  
  

Working Conditions & Physical Requirements

• This job operates in an office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, scanners, filing cabinets and fax machines.
• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand on a stool as necessary. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
  
  

Please note this job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities that are required of the employee for this job. Job responsibilities, location, work hours, etc., may change at any time with or without notice.