Transition Of Care II, LVN

This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.

Why Join Us?

We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Transitions of Care Licensed Vocational Nurse II (TOC LVN II) is an experienced clinical care coordinator responsible for supporting members with moderate to complex transition of care needs following inpatient admissions, emergency department visits, skilled nursing facility stays, and other qualifying transitions. Working under the direction of a Registered Nurse and within the scope of California LVN licensure, the TOC LVN II independently coordinates transition activities, reinforces individualized care plans, identifies barriers to care, and promotes member engagement to improve health outcomes and reduce avoidable readmissions.

In addition to direct member care coordination, the TOC LVN II serves as a clinical resource for LVN I staff, supports onboarding and workflow consistency, participates in quality improvement initiatives, and collaborates with interdisciplinary teams to ensure compliance with CMS, NCQA, organizational policies, and regulatory requirements.

Functions & Job Responsibilities

• Independently coordinate transitions of care activities for members with moderate to complex healthcare needs in accordance with departmental workflows and regulatory requirements.
• Conduct comprehensive telephonic member assessments within the LVN scope of practice and communicate clinical findings to the Registered Nurse for evaluation and care planning.
• Review discharge instructions, medication regimens, follow-up appointments, and care plans with members and caregivers to reinforce understanding and identify barriers requiring intervention.
• Assist with medication reconciliation by obtaining medication histories, identifying discrepancies, and escalating clinical concerns to the Registered Nurse, pharmacist, or prescribing provider.
• Coordinate post-discharge services including physician appointments, home health, durable medical equipment, transportation, pharmacy services, and community resource referrals.
• Identify social determinants of health that may impact recovery or treatment adherence and coordinate referrals to the Registered Nurse, Social Worker, or appropriate community resources.
• Monitor member progress throughout the transition period, recognize changes in condition, and promptly communicate concerns requiring clinical intervention.
• Serve as a resource to LVN I staff by providing guidance on workflows, documentation standards, transition protocols, and departmental processes.
• Assist with onboarding, orientation, and day-to-day support of new LVN staff as assigned.
• Collaborate with Registered Nurses, Social Workers, Utilization Management, Case Management, Medical Directors, hospitals, physician offices, skilled nursing facilities, home health agencies, pharmacies, and other healthcare partners to facilitate continuity of care.
• Participate in interdisciplinary care team meetings by providing member updates and identifying care coordination needs.
• Maintain timely, accurate, and audit-ready documentation in accordance with CMS, NCQA, HIPAA, and organizational standards.
• Support quality improvement initiatives, documentation audits, workflow improvement activities, and corrective action plans.
• Identify opportunities to improve care coordination processes and communicate recommendations to leadership.
• 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.
• Perform other duties within the scope of LVN licensure as assigned.