Job Description
Job DescriptionSalary: Starting at $20, DOE
The Chronic Disease LVN is responsible for managing and delivering the One Year to a Healthier You (OYHY) programan integrated, community-based chronic disease and cancer prevention initiative targeting patients with or at risk for diabetes, hypertension, obesity, and related health concerns. This role combines care coordination, health education, nutrition support, and community outreach to improve health outcomes and promote sustainable behavior change among program participants.
This position will serve as the primary point of contact for referred patients, oversee intake and follow-up, deliver group and individual education sessions, and collaborate with TAN clinical staff, behavioral health, and external partners such as Market to Hope.
Essential Job Responsibilities:
Patient Engagement & Coordination
Receive and process patient referrals from TAN providers and LVNs
Conduct comprehensive intake assessments, including social determinants of health
Develop individualized care plans focused on lifestyle modification
Coordinate care across TAN departments (e.g., primary care, behavioral health)
Program Delivery & Education
Lead individual and group health education sessions on:
Healthy eating and the CDC Healthy Plate model
Portion control and food label reading
Sodium reduction and cancer prevention
Physical activity strategies and behavior change techniques
Track patient progress, including biometric data and session participation
Provide regular follow-up, motivation, and accountability to program participants
Facilitate patient understanding and use of Remote Patient Monitoring (RPM) tools
Community Collaboration & Outreach
Partner with Market to Hope to coordinate food box distribution and community screenings
Support education of Market to Hope staff and volunteers through training sessions and video materials
Participate in outreach events and assist with promotion of the OYHY program
Documentation & Reporting
Maintain accurate and timely documentation in the Electronic Health Record (EHR)
Submit monthly reports detailing patient engagement, outcomes, and service delivery
Assist in grant compliance, outcome tracking, and quality improvement efforts
Perform other duties as assigned.
Minimum Education, Qualifications and Experience:
Licensed Vocational Nurse degree from an accredited school of nursing with current unrestricted license from the Texas Board of Vocational Nurse Examiners to practice as a licensed vocational nurse (LVN) in the State of Texas
Minimum of 2 years experience in chronic disease management, health education, or care coordination
Strong understanding of social determinants of health and health disparities
Experience facilitating group education or wellness classes
Excellent interpersonal, organizational, and communication skills
Proficient in Microsoft Office and comfortable with EHR documentation
Preferred:
Bilingual (Spanish/English) strongly preferred
Familiarity with Southeast Texas community resources and population health needs
Work Environment & Physical Requirements:
Hybrid office and field-based role
Must be able to sit, stand, and walk for extended periods
Requires local travel to food pantry locations, community events, and TAN clinics