LVN Service Coordinator in San Bernardino, California at Step-Up on 2nd Street

Inland Empire ECM Program
LVN Service Coordinator

JJOB TITLE: Licensed Vocational Nurse Serice Coordinator

REPORTS TO: Program Manager

HOURS: Full-Time

REQUISITION NUMBER: 1812

SUMMARY: The Licensed Vocational Nurse (LVN) provides care coordination and clinical support services to members enrolled in the Enhanced Care Management (ECM) program. The LVN works collaboratively with an interdisciplinary care team to support members with complex medical, behavioral health, and social needs. This position assists with care planning, member engagement, health education, care transitions, and coordination of services to improve health outcomes and reduce barriers to care. All team members must adhere to Medi-Cal, Medicare, IEHP, and Molina documentation standards. The Nurse Service Coordinator works collaboratively with Step Up's interdisciplinary teams to provide members with high-
quality medication support and care management. The Nurse Service Coordinator must
demonstrate behavior consistent with Step Up's core values.

BENEFITS AND WHAT WE OFFER:

DUTIES: The following reflects essential functions for this job but does not restrict other tasks which may be assigned:

Direct Service and Support

Care Management & Coordination

• Support the development, implementation, and monitoring of individualized Care Management Plans.
• Participate in comprehensive health assessments and reassessments.
• Coordinate care among primary care providers, specialists, behavioral health providers, hospitals, and community agencies.
• Identify gaps in care and assist in addressing member health needs.
• Track referrals and ensure follow-up on recommended services.
• Assist with medication review, adherence support, and care coordination activities.

Member Engagement & Outreach

• Conduct member outreach and engagement activities through in-person, telephonic, or telehealth encounters.
• Support enrollment and onboarding of eligible ECM members.
• Build trusting relationships with members and families to encourage active participation in care.
• Assist with appointment scheduling, reminders, transportation coordination, and accompaniment to critical appointments when appropriate.

Health Promotion

• Educate members on disease prevention, chronic disease management, medication adherence, and healthy lifestyle choices.
• Support members in self-management of chronic health conditions.
• Encourage utilization of preventive health services and screenings.
• Promote wellness activities and community-based support resources.

Transitional Care Support

• Participate in post-discharge follow-up activities for members transitioning from hospitals, emergency departments, skilled nursing facilities, residential treatment programs, or correctional facilities.
• Contact members within established timelines following discharge.
• Assist with transition planning and coordination of follow-up care.
• Monitor members at risk for readmission and assist in reducing avoidable hospitalizations.

Documentation & Compliance

• Document all care management activities in the approved care management platform and electronic health record systems.
• Submit timely, accurate encounter documentation according to ECM and IEHP requirements.
• Maintain compliance with HIPAA, Medi-Cal, CalAIM, ECM, and organizational policies.
• Participate in audits, quality improvement initiatives, and data reporting activities.

Team Collaboration

• Participate in multidisciplinary case conferences and Systematic Caseload Review meetings.
• Collaborate closely with Registered Nurse Care Managers, Behavioral Health Care Managers, Care Coordinators, Community Health Workers, physicians, and community partners.
• Assist in implementation of quality improvement and population health initiatives.
• Participate in required ECM trainings, coaching sessions, and continuing education.

SKILLS: Highly skilled interpersonally, with excellent relationship skills. Will have demonstrated strong analytical skills within a health care setting and related areas within scope. Knowledge of chronic disease management principles. Understanding care coordination and case management practices. Familiarity with Medi-Cal and Enhanced Care Management (ECM) programs. Knowledge of social determinants of health and community resource navigation.

Strong communication, organizational, and interpersonal skills. Ability to work effectively with diverse populations. Proficiency with electronic health records and Microsoft Office applications. Ability to maintain confidentiality and comply with HIPAA requirements.

QUALIFICATIONS: (Education & Experience)

Graduate of an accredited Vocational Nursing program. Licensure Current and unrestricted California Licensed Vocational Nurse (LVN) license. Current CPR/BLS certification. Experience Minimum one (1) year of clinical nursing experience preferred. Experience in care management, case management, ambulatory care, community health, managed care, or population health preferred. Experience working with Medi-Cal populations and high-risk members preferred. Experience in a Health Care Organization or experience in Managed Care setting preferred. A valid California driver’s license and clean driving record. A reliable vehicle and valid automobile insurance is mandatory, as automobile travel is required in the Inland Empire either by personal or company vehicle. Step Up will verify these requirements. A clean report Department of Justice background check.

SUPPLEMENTAL INFORMATION: Work with people experiencing homelessness whether on the streets, in shelters or other places of habitation or services, may present inherent challenges and difficulties such as: exposure to bed bugs or other infestations, unpleasant smells or odors, individuals who may have poor hygiene or unclean homes due to homelessness, mental health symptoms, or poverty. Additionally, in working with our members, employees may encounter instances of profanity, sexually explicit or derogatory language, or verbal or physical expressions of anger and trauma. Very rarely do these situations ever escalate to physical contact, and negative or derogatory communication patterns can often be negotiated successfully. All direct care staff are provided adequate training to develop skills to deescalate crisis situations that may arise and Step Up has established procedural safeguards for all employees to mitigate (but not eliminate) these inherent risks of employment.

Please Note: This position is part of the Service Employees International Union (SEIU721) Bargaining Unit.

PHYSICAL REQUIREMENTS: While performing the duties of this job, the employee is regularly required to sit; use hands and fingers; handle or feel; reach with hands and arms; talk; and hear. The employee is frequently required to walk, balance, stoop, kneel, and/or crouch. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Keyboard data entry required.

Step Up utilizes the principles of trauma-informed care and mental health recovery. These principles inform our Core Values of Hope, Wellness, Voice and Choice, Respect, and Collaborative Relationships. As representatives of Step Up, employees agree to adhere to these values in their interactions with members, colleagues, supervisors, and associated community members.

STEP UP CORE VALUES

HOPE – We believe all people have the capacity for positive growth and change. We use hope to inspire and motivate ourselves, our members, our colleagues, and our community.

WELLNESS – We believe in promoting a culture that supports healthy and fulfilling lives. We use a supportive environment to foster well-being for ourselves, our members, our colleagues, and our community.

VOICE AND CHOICE – We believe in the right to choose and be heard. We use voice and choice to create meaningful outcomes and empowerment for ourselves, our members, our colleagues, and our community.

RESPECT – We believe in promoting interactions that are non-judgmental, transparent. We use respect to guide all of our words and actions with ourselves, our members, our colleagues, and our community.

COLLABORATIVE RELATIONSHIPS – We believe in forming partnerships to share resources, knowledge, and experiences. We use collaborative relationships to strengthen accomplishments for ourselves, our members, our colleagues, and our community.

Step Up provides equal employment opportunities without regard to age, ancestry, color, creed, mental or physical disability, marital status, medical condition, national origin, race, religion, sex, sexual orientation, veteran status, or any other consideration made unlawful by federal, state, or local laws.

STEP UP IS AN EQUAL OPPORTUNITY EMPLOYER