About this role
The Care Manager, LVN supports Astrana Health’s mission to improve patient outcomes by providing transitional care management, high-risk care management, and ongoing follow-up for members across multiple health plans and populations after hospital discharge. The nurse conducts clinical assessments, coordinates care, ensures medication safety, assists with closing quality gaps, and promotes member engagement through regular outreach and education. Comply with Astrana and department policies and procedures. Assess the medical, social, and behavioral needs of members. Complete comprehensive member assessments within required timeframes and identify individuals who may benefit from case management using clinical judgment, observed health or psychological changes, and assessment-driven triggers. Ensure timely, accurate, and complete documentation in all systems. Develop and implement an individualized case management plan in collaboration with the member, caregiver, social worker, physician and/or other involved healthcare professionals and the member’s support person to address member needs and goals. Collaborate with hospitalists, inpatient case managers, and discharge planners to establish safe discharge plans beginning at admission. Review medical records and/or other documentation to determine medical necessity. Conduct medication reconciliation post-discharge. Review medications for accuracy, missing medications, duplications, and potential interactions. Promote medication adherence through reminders, education, and barrier reduction. Close open quality measure gaps. Review member profiles and medical records to identify open care gaps and assist in closing the gaps when applicable. Attend and participate in company meetings, team meetings, and IDT meetings. Other duties and tasks as assigned.