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POSITION DETAILS

POSITION SUMMARY:

The Lead Care Manager – Registered Nurse is responsible for providing comprehensive patient-centered case management and care coordination services to patients with complex medical, behavioral and social needs.  The Lead Care Manager – Registered Nurse assesses patients needs, develop and monitors individual care plans, coordinates services across healthcare providers and community resources, and promote continuity, quality and positive health outcomes. 

The Lead Care Manager – Registered Nurse works collaboratively with healthcare teams to identify high-risk patients, address barriers to care, support chronic disease management, provide patient and family education, and advocate for appropriate cares based on patients’ needs. The Lead Care Manager – Registered Nurse must maintain accurate and timely records of patient information, encounters and ensure compliance with local, state and federal regulations.

The duties and responsibilities described in this job description are intended to provide a general overview of the position and are not intended to be an exhaustive list of all tasks, duties, or responsibilities. Management reserves the right to modify, assign, or reassign duties and responsibilities as necessary to meet organizational needs. Reasonable accommodation may be provided as necessary to perform the essential functions of this position.

• Providing management oversight of the ECM benefit which provides for a whole person approach to care to address the clinical and non-clinal circumstances of high need
• Identifying, developing and implementing program partnerships, care delivery models, and community-based health practices to successfully achieve ECM’s strategic and tactical objectives
• Providing leadership and support for successful integration of ECM services through interdepartmental collaboration, integration, and communication across all departments
• Conducting meetings with ECM Staff 
• Collaborating with internal stakeholders to ensure that ECM providers are aware of the ECM Unit’s core service components and delivery strategies
• Researching and identifying ECM best practices and sharing that information with ECM providers and care teams
• Collaborating with staff across all departments to ensure that ECM services and benefits are implemented according to contractual requirements
• Interviewing and participating in the selection of staff in conjunction with ECM Director
• Collaborating with the ECM Director in developing staff training plans, career pathways and routine individual staff performance reviews
• Evaluating employee performance, providing feedback to staff, and coaching and counseling or disciplining staff when performance issues arise
• Overseeing or conducting staff training, including the development and maintenance of training materials, in conjunction with the Training and Development team
• Identifying training gaps and opportunities for improved performance
• Overseeing staff in multiple office locations and/or telecommute settings
• Performing assessments and creating care plans for escalated ECM patient cases
• Conduct home visits to participants of the program to assess participant’s health needs, living conditions, and risk factors 
• Assist in addressing barriers to healthcare access, such as transportation, insurance, or language barriers.
• Monitor vital signs of patient and health outcomes
• Conduct regular follow-up visits to ensure patients comply with treatments and care plans
• Assist patients with managing conditions such as diabetes, hypertension, or asthma by reinforcing medical guidance
• Document interactions with participants, health assessments, and services provided during home visits
• Prepare and submit reports on participant progress, referrals and follow-up to healthcare teams
• Ensure all documentation follows HIPAA and other relevant privacy laws and regulations 
• Obtain signed consent forms and documentation for participants
• Adhere to the health center and program policies and procedures 
• Attend and complete all required training courses as directed by management 
• Travel to and from clinics and participant’s home as necessary
• Identify and reach out individuals in underserved communities who may benefit from the program services
• Evaluate individuals for qualifications and eligibility into the program
• Advocate for participants health needs and helping participants navigate healthcare and social services.
• Refer participants to healthcare providers, social services, and community resources
• Educate and support participants in navigating healthcare systems
• Perform other duties as assigned.

Required Certifications, Training/Education and Experience

• Valid Register Nurse License with the State of California
• 1 year of experience in case management 
• 1 year of experience working with underserved patient populations 
• Valid Driver’s License with clean/good driving record
• Clean fingerprinting/livescan 

Required Skills and Competencies

• Strong analytical and critical thinking abilities to assess and evaluate patients with complex medical, behavioral and social needs.
• Proficient care coordination and care planning skills
• Ability to advocate for patients needs by identifying barriers to care and facilitating access to appropriate services
• Provide clear, culturally responsive education regarding medical diagnosis, medication, treatment plans, preventive care service 
• Ability to identify and connect with patients with appropriate healthcare, behavioral health, social services, financial, transportation, housing and other community resources. 
• Ability to maintain accurate, timely and comprehensive documentation of patient encounters, health records
• Excellent verbal and written communication skills for interacting with patients, families, and healthcare teams.
• Ability to build rapport with patients and work collaboratively with healthcare professionals.
• Efficient time management skills to handle a busy and varied caseload.
• Ability to provide empathetic and compassionate care to patients of all ages.
• Effective problem-solving skills to address complex patient needs and healthcare challenges.
• Familiarity with electronic health records (EHR) and other healthcare technology.
• Knowledge of healthcare regulations, patient privacy laws (e.g., HIPAA), and ethical standards.
• Familiarity with evidence-based clinical guidelines and best practices.
• Understanding of public health principles and community health issues.

Physical Requirements

• Ability to sit, stand, walk, and use standard office equipment for extended periods. 
• Ability to occasionally lift and carry up to 20 pounds.
• May require occasional travel between work locations or attendance at training sessions.

BENEFITS

A comprehensive benefit package for eligible employees and their eligible dependents as follows:

• Medical, Life, Dental & Vision Insurance 
• 401(K) and Profit Sharing 
• Paid Time off and Paid Sick Leave
• Six Paid Holidays 
• Short-Term and Long-Term Disability 
• Gym Membership Allowance 
• Telemedicine Program 
• Legal and Identity Shield

This position primarily works in a healthcare setting that may include medical, dental, behavioral health, and administrative environments. Employees may be exposed to communicable diseases, bloodborne pathogens, bodily fluids, medical equipment, cleaning agents, and other conditions commonly associated with healthcare operations. Employees are expected to follow all infection prevention and control procedures, safety protocols, and use required personal protective equipment (PPE).

Employment with the organization is at will and may be terminated by either the employee or the organization at any time, with or without cause or advance notice, subject to applicable federal, state, and local laws. Nothing contained in this job description shall be construed as creating an employment contract, expressed or implied.

The organization is an Equal Opportunity Employer and is committed to providing a workplace free from discrimination, harassment, and retaliation. Employment decisions are made without regard to race, color, national origin, ancestry, age, disability, sex, gender identity, gender expression, sexual orientation, religion, marital status, veteran status, genetic information, or any other protected status under applicable law.