- Manage target engagement list (TEL) provided by contracted health plans.
- Conduct outreach as required to all TEL patients and referred eligible patients within an appropriate time frame.
- Develop and document a person centered health action plan in collaboration with the patient and or family support.
- Maintain at minimum, one telephonic visit which is documented and minimum one in-person visit every 3 months for each enrollee. More frequent contacts made as determined by acuity and complexity of enrollee.
- Notifies clinical consultant, PCP or health homes director of complex behavioral or medical psycho-social issues.
- Other duties as assigned.
- A Valid Licensed Vocational Nurse license issued by the State of California is required.
- A minimum of two years as an LVN with patient care experience, knowledge of care coordination, continuity of care processes and care management.
- Fully fluent in English and Spanish.