Job Summary:
The Nurse Care Manager for the Enhanced Care Management (ECM) - Community Supports (CS) program plays a pivotal role in supporting the program by ensuring the delivery of high-quality clinical care to ECM Members with complex medical conditions. The Nurse Care Manager is responsible for managing a caseload of members, primarily those with complex medical needs, ensuring that their health and wellness goals are met through comprehensive care management and coordination. This position involves conducting medication reconciliations, educating members and their families on chronic medical and behavioral health conditions, and collaborating with the ECM Care Team to ensure seamless transitions of care. The Nurse Care Manager also uses evidence-based communication strategies to engage members and promote a healthy lifestyle, with the overarching goal of improving clinical outcomes and enhancing the overall quality of life for the individuals served by the program. The Nurse Care Manager’s role is integral in reducing unnecessary hospitalizations and optimizing the delivery of care within the ECM framework.
Essential Duties:
- Supports ECM Members with complex medical conditions and completes medication reconciliation in collaboration with pharmacy as available for all ECM-enrolled Members.
- Primarily works with a caseload of Members with complex medical needs (primarily Tiers 1 and 2 as defined in the Risk Grouping section).
- Engages Members and supports/encourages Member activation towards achievement of health goals.
- Promotes a collaborative and effective working environment within the ECM by engaging in evidence-based communication strategies (such as Motivational Interviewing) when discussing responsibility/sharing of tasks, effectively resolving conflicts, and collaborating on Member case discussions.
- Tracks medical and behavioral health outcome measures in the web-based care management platform or equivalent platform.
- Provides Member and family education about chronic medical and behavioral health conditions to improve health literacy.
- Gathers input from other ECM Care Team members to prioritize Member cases for systematic population/caseload review.
- Facilitates and ensures recommendations are communicated across the healthcare team.
- Works with Members to identify health/wellness goals and incorporates these goals into Health Action Plans/Shared Care Plans that facilitate communication among Members and Providers.
- Champions healthy lifestyle changes.
- Coordinates physical care management and care coordination relationships with external healthcare Providers.
- Receives, identifies, and follows-up treatment and medication alerts.
- Consults with the ECM Care Team members about clinical concerns or questions and provides educational training on chronic disease states, prevention, treatment, medications, and healthy living.
- Ensures smooth transitions of care, coordination with hospitals for M1 or with IEHP transitions of care team for M2, regarding Member admission/discharges.
- Conducts medication reconciliations with input from the Member’s PCP.
- Tracks and assures required assessments and screenings are performed, including Comprehensive Health Assessment and Shared Care Plan.
- Reviews Comprehensive Health Need Assessments (splits role with BHCM) upon completion by other care team members.
Education and Experience:
Required:
- Registered Nurse (RN) or Licensed Vocational Nurse (LVN) with the California Board of Registered Nursing
- Minimum of 5 years nursing experience, with at least 2 years in care management, population health, or related field.
- Expert knowledge of healthcare practices, care coordination, and patient-centered care.
- Strong analytical skills with the ability to interpret clinical data and translate findings into actionable strategies.
- Willingness to travel locally as needed to support program initiatives, trainings, and stakeholder engagement.
Preferred: Previous Clinical experience working with individuals recently released from jail or prison a plus. Previous Supervisory experience.
Certifications or Licenses:
- Required: RN or LVN
- Preferred: NONE.
- Driver’s License
Skills/Abilities:
- Excellent organizational skills and attention to detail.
- Excellent written and oral communication skills.
- Extensive knowledge of non-profit organizations.
- Proficient in Microsoft Office Suite or similar software.
- Knowledge of contracting process and associated local, state, federal and other regulations.
- Ability to multi-task, identify problems, provide recommendations to management teams, and implement any applicable systems.
- Ability to work constructively with diverse people and with parties that may have divergent perspectives and interests.
- Understand and appropriately apply Amity policies and procedures and adhere to agency-wide practices and regulations.
ADA Information:
Physical Requirements:
- Faculty must frequently lift and/or move up to 50 pounds.
- Frequently required to sit and/or stand for extended periods of time.
- Frequently required to type for extended periods of time.
- Occasionally required to reach, walk, climb, pull, push, grasp, stretch, stoop.
- Frequently required to talk, hear, see, and use repetitive motions.
- Frequently able to communicate in verbal and written form.
- Frequently able to use all types of vision, such as close vision, distance vision, color vision, peripheral vision, and depth perception, to complete daily tasks.
- Required to wear comfortable and office appropriate clothes.
Mental Demands:
- Ability to change direction as priorities shift.
- Ability to thrive in an environment that requires one to adapt to changing circumstances.
- Ability to professionally work under pressure with difficult or temperamental students & faculty.
- Ability to handle mental and emotional stress related to the position.
Work Conditions:
- Community based and office setting.
Environmental Conditions:
- The noise level in the work environment is moderate but can be loud.
- The temperature in the work environment is usually moderate to cool but can be cold or hot.
Travel:
- May travel locally by vehicle.
Note: This job description is intended to describe the general nature and work responsibilities of the position. It is not possible or desirable to commit every detailed aspect of each job to a written description. This job description and the duties of this position are subject to change, modification, and addition as deemed necessary by the company. Job descriptions alone cannot be used as an argument to refuse work assignments. Faculty are required to comply with supervisory instructions and perform other job duties, responsibilities and assignments required by company officials. This job description does not constitute an employment contract between the company and any employee. The job responsibilities of this position may include cross-training in other functions to ensure satisfactory operation.
