LPN Care Manager CTO Transition of Care

General Summary of Position
Provides care coordination for hospitalized patients within CTO (Care Transformation Organization) -supported practices, partnering with the interdisciplinary team and serving as a key liaison to ensure seamless care across settings. 

The LPN Transition of Care Nurse supports high-risk and episodic patients—primarily within the Medicaid population—through safe, coordinated transitions from hospital to home or other care settings. This hybrid role offers remote flexibility while requiring regular travel to hospitals and the community to engage patients in person.

In this role, the LPN partners with care teams to meet patients during hospitalization, ensuring continuity of care, reducing readmissions, and addressing clinical and social needs. Strong Medicaid experience is essential, along with a well-rounded background that includes both hospital-based care and community, outpatient, or ambulatory case management.

This is a hands-on, patient-facing role that requires routine hospital visits. Mileage and parking for required travel are reimbursed. The ideal candidate is self-directed, organized, and passionate about improving outcomes for vulnerable populations. This would also include the PG County area hospitals and potential travel to the Baltimore area as needed. 

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• In collaboration with the interdisciplinary care team acts as primary care team agent for the episodic care needs and coordination of care for a panel of attributed Medicare beneficiaries following discharge by ensuring the following: Ensures attributed beneficiaries have timely access to care (same day or next day access to the patient's own practitioner and/or care team for urgent care or transition management); Assists patients with scheduling appointments with providers including annual wellness visits. Review of Discharge instructions and Medication Reconciliation
• Attributed beneficiaries receive a follow up interaction from the TOC Care manager coordinator within 2 business days for hospital discharge and within one week for Emergency Department (ED) discharges; Coordinates referral management for attributed beneficiaries seeking care from high-volume and/or high-cost specialists as well as EDs and hospitals; Facilitates connection to services for patients who may benefit from behavioral health services including: patients with serious mental illness patients with substance use disorders' patients with depression anxiety or other mental health conditions patients with behavioral and social risk factors and BH issues patients with multiple co-morbidities and BH issues; elevates patients requiring longitudinal / ongoing care management needs following discharge to the CTO Lead Care manager MDPCP Social needs teams and or MDPCP Amb pharmacist where appropriate
• Completes general assessment for barriers or needs including any Social Determinants of Health (SDoH) and makes referrals as appropriate
• Assesses plans implements monitors and evaluates options and services to meet health needs of attributed beneficiaries up to 30days following In patient discharge or Emergency room visit . Manages a caseload in compliance with contractual obligations and the MD Primary Care Program (MDPCP) standards.
• Monitors and evaluates effectiveness of care plan and modifies plan as needed. Supports member access to appropriate quality and cost-effective care. Coordinates with internal and external resources to meet identified needs of the member's care plan and collaborates with providers
• Acts as a liaison and member advocate between the member/family physician and facilities/agencies. Provides clinical consultation to physicians professional staff and other teams members/supervisors to provide optimal quality patient care and effective operations.
• Ensures members are engaging with their PCP to complete their care management treatment plan or preventive care services.
• Ensures daily telephonic patient communication to help to close gaps in care and provide up-to-date healthcare information helping to facilitate the members understanding of his/her health status using available reports including quality m page and HIE CRISP to ensure relevant medical history/encounter are accessible in EMR.
• Facilitates ongoing communication amongst practice and care team by participating in huddles hosting regular conference calls in-person meetings or coordinating regular email updates to ensure alignment of activity discuss new developments and exchange information.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.

Minimal Qualifications
Education

• Associate's degree from National League for Nursing accredited program required or
• Diploma from National League for nursing accredited program. required

Experience

• 3-4 years Related experience required

Licenses and Certifications

• LPN - Licensed Practical Nurse - State Licensure Valid Maryland LPN License required and
• CPR - Cardiac Pulmonary Resuscitation Active ALS/CPR certification required and
• DL - Valid State Driver's License in good standing Valid driver's license required

Knowledge Skills and Abilities

• Basic computer skills preferred.
• Effective verbal and written communication skills.
• Excellent interpersonal and customer service skills especially serving geriatric patients.
• Strong analytical and critical thinking skills.
• Strong community engagement and facilitation skills.
• Advanced project management skills.
• Commitment to collective impact concepts.
• Flexibility and the ability to work autonomously as well as take direction as needed.
• Cultural competency.
• Proficient computer skills along with experience using Microsoft applications-Word Excel etc. and familiarity with entering data in an electronic medical record (EMR).