Post Acute Care Coordinator LPN

Advanced Management USA LLC • Full-time • Murrieta, CA, US • $60,000 / year • 3w ago

Job description:

Position Summary:

The Post-Acute Care Coordinator LVN plays a key role in improving care transitions for Medicare patients by managing discharges from acute or post-acute facilities and ensuring patients receive appropriate, timely follow-up care. This position is integral to achieving CMS-aligned goals, such as reducing readmissions, improving quality scores, and enhancing the patient experience across the continuum of care.

Key Responsibilities:

Coordinate discharge planning from hospitals or skilled nursing facilities (SNFs) to home or other care settings.
Ensure timely scheduling of follow-up appointments and home care services in accordance with CMS guidelines.
Monitor patients throughout their post-acute journey using internal ACO care tracking systems.
Collaborate with providers, patients, and caregivers to ensure understanding of post-discharge instructions and care plans.
Identify and escalate care barriers that impact quality or outcomes.
Conduct on-site and virtual visits with SNFs, home health agencies, and provider offices.
Provide onboarding and education to practices and facilities on care coordination protocols and quality initiatives.
Support CMS initiatives related to transitional care management (TCM), 3-day SNF waiver, and patient engagement.
Maintain accurate documentation in internal care platforms for audit and reporting purposes.
Adhere to all HIPAA, regulatory, and organizational compliance standards.

Qualifications:

Required:

Minimum 2 years of experience in a skilled nursing facility, home health, hospital discharge planning, or provider relations.
Valid California Vocational Nurse license
Valid and unrestricted driver’s license with reliable transportation.
Proficiency in using technology platforms for care coordination and communication.
Proficiency in Microsoft Excel and Data Analysis

Preferred:

Bachelor’s degree in Nursing, Health Administration, or a related field.
Knowledge of CMS ACO programs and transitional care processes.
Experience working in a value-based care or ACO setting.

Skills & Competencies:

Strong interpersonal and communication skills.
Independent problem-solving ability.
Highly organized and detail-oriented.
Comfortable with remote work and flexible scheduling.
Commitment to delivering high-quality, patient-centered care.

Physical & Travel Requirements:

Must be able to travel locally and regionally (up to 50%) for in-person meetings and site visits within the surrounding San Marcos area.

Salary & Benefits:

Salary:$60,000+ per year (commensurate with experience)

Benefits Include:

Competitive health, dental & vision insurance
401(k) retirement plan with company match
Stock options opportunities
Paid Time Off (PTO) and paid holidays
Paid parental and bereavement leave
Remote work flexibility
Company-issued technology and ongoing training support

Advanced Management USA is an equal opportunity employer and drug-free workplace. All employment is contingent upon successful completion of a drug screen, background check, reference verification, health assessment, and credential/license verification.