Transition of Care II, LVN

About the role

The Transitions of Care Licensed Vocational Nurse II (TOC LVN II) position operates on a hybrid work schedule, requiring 3 days onsite at either the Monrovia or Huntington Beach office.

Responsibilities

• Independently coordinate transitions of care activities for members with moderate to complex healthcare needs.
• Conduct comprehensive telephonic member assessments and communicate clinical findings to the Registered Nurse.
• Review discharge instructions, medication regimens, follow-up appointments, and care plans with members and caregivers.
• Aid in medication reconciliation by obtaining medication histories and escalating clinical concerns.
• Cook up post-discharge services including physician appointments, home health, durable medical equipment, transportation, pharmacy services, and community resource referrals.
• Identify social determinants of health impacting recovery or treatment adherence and coordinate referrals.
• Maintain progress throughout the transition period, recognizing changes in condition, and promptly communicating concerns.
• Serve as a resource to LVN I staff, providing guidance on workflows, documentation standards, transition protocols, and departmental processes.
• Collaborate with interdisciplinary teams to ensure compliance with CMS, NCQA, organizational policies, and regulatory requirements.
• Support quality improvement initiatives, documentation audits, workflow improvement activities, and corrective action plans.
• Promote culturally responsive, member-centered care that respects each member's individual preferences, values, and healthcare goals.
• Maintain current knowledge of Medicare Advantage requirements, transitions of care best practices, and organizational policies.
• Participate in continuing education and professional development activities.

Qualifications

• Current, unrestricted California Licensed Vocational Nurse (LVN) license.
• Minimum of four (4) years of progressive LVN clinical experience.
• Minimum of two (2) years of experience in Care Management, Case Management, Population Health, Managed Care, Transitional Care, Home Health, Primary Care, Utilization Management, or Hospital Discharge Planning.
• Experience coordinating care for members with chronic and complex medical conditions.
• Experience supporting quality improvement initiatives, mentoring staff, or participating in workflow improvement activities preferred.
• Medicare Advantage or managed care experience strongly preferred.
• Advanced knowledge of Medicare Advantage, CMS regulations, NCQA accreditation standards, and transitions of care workflows.
• Thorough understanding of the California LVN scope of practice and ability to recognize situations requiring Registered Nurse assessment or intervention.
• Strong knowledge of chronic disease management, discharge planning, care coordination, and community resource navigation.
• Ability to independently manage a complex workload while maintaining quality and regulatory compliance.
• Demonstrated ability to mentor, coach, and support less experienced staff in clinical workflows and documentation standards.
• Strong critical thinking and organizational skills with the ability to prioritize competing demands and meet regulatory timeframes.
• Excellent verbal, written, and interpersonal communication skills with members, caregivers, providers, and interdisciplinary teams.
• Proficiency with electronic health records, care management platforms, Microsoft Office Suite, and virtual communication technologies.
• Ability to identify process improvement opportunities and contribute to departmental quality initiatives.
• Commitment to member advocacy, teamwork, professionalism, cultural competence, and continuous learning.
• Bilingual in Mandarin/Cantonese, Vietnamese, Korean, or Spanish preferred.