Post Acute Care Coordinator LPN

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.