LVN, Post Acute Care Manager

Company Details

Memorial Hermann Health System

At Memorial Hermann, we’re about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

Responsible for providing care management services and support to an assigned population with the purpose of improving health outcomes via a coordinated approach. The Care Manager I works in collaboration and continuous partnership with patients and their family members, as well as clinic, hospital, post-acute and insurance company partners, along with community resources, to achieve the desired outcomes. Using a defined process to identify patients/members in need of care coordination services, the LVN, Post Acute Care Manager coordinates care transitions and wellness activities throughout the care continuum for patients assigned to the care management programs with the goal of enhancing patient health and well-being, improving adherence to health programs, and reducing health care costs.

Must be highly collaborative with strong customer service skills and be able to demonstrate the ability to actively engage patients in positive relationships. Must also be able to demonstrate the knowledge and skills necessary to provide care management services appropriate to the patient/member being served.

The Transitional Care Management team is unique because it bridges the gap between traditional inpatient case management and ambulatory case management. We work with patients at the bedside and then continue that outreach across the post discharge continuum of care, with the goal of ensuring excellent transitions of care through the use of interventions targeted at gaps and barriers of care in the patient’s home and community.

Job Description

Minimum Qualifications

Education: High School Diploma or GED required
and graduate from an accredited school of vocational nursing or licensed practical nursing

Licenses/Certifications: Active LVN license in the State of Texas

Experience / Knowledge / Skills:

  • Three (3) years clinical healthcare experience required
  • One (1) year of experience in care coordination and planning, chronic disease management or population health preferred
  • Ability to demonstrate knowledge of ACO initiatives and care management processes
  • Experience working in interdisciplinary teams
  • Excellent computer skills
  • Excellent communication and interpersonal skills
  • Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principal Accountabilities

  • Provides care coordination services to identified patients/members enrolled in the Transitions of Care, Wellness, and Complex Care Management programs.
  • Provides proactive outreach to members to include telephonic, internet, or face-to-face encounters.
  • Works cohesively with other health management disciplines to assist patients/members in problem-solving potential issues related to financial, environmental and psychosocial barriers, as well as problems with the overall system of care.
  • Manages and facilitates relationships with post-acute providers, physicians, and community resources to increase continuity of care.
  • Coordinates warm hand-off to primary care providers and other partners throughout the care continuum as patient/member has a transition in care and/or completes the necessary wellness activities.
  • Assists patient/member with medication management and compliance, including a medication review, and make referrals to other Care Management team members, such as a nurse Care Manager or Pharmacist, to promote medication adherence.
  • Provides chronic disease and self-management education and support to improve comprehension, health literacy and adherence to established plan of care.
  • Utilizes decision support tools and escalation protocols to support decision-making, efficient utilization of clinical resources, increase use of established network providers and reduce emergency room utilization and hospital readmissions.
  • Performs review of discharge instructions and other healthcare-related documents with patients/members to facilitate understanding and adherence.
  • Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
  • Other duties as assigned.

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