CalAIM ECM Nurse Case Manager — Transform Community Care

Stepping-Up-Santa-Cruz; Santa Cruz (CA); On-site; USD 100,000 - 107,000; Full time

Benefits offered by this job

No-cost health coverage with dental/vo

Simple IRA with 100% match up to 3%

Paid time off (3 weeks) per year

Sick leave (5 days) per year

Job summary

Stepping Up Santa Cruz is looking for a CalAIM Nurse Case Manager to join our care coordination team in Santa Cruz. You will manage a small caseload enrolled in ECM and CS programs, perform medication reconciliation, and advocate for trauma-informed, person-centered care.

This on-site role involves collaboration with physicians, therapists, social workers, and community partners, overseeing care plans, discharge planning, and home visits.

Qualifications

• RN from an accredited school with California registration.

Responsibilities

• Manage a small caseload to ensure understanding of processes and see areas for improvement.
• Help members with complex needs get assistance by coordinating and helping to manage their care.
• Pull outside medical records, including CCAH and SCHIO the local health information exchange (HIE), provide updates to medical care team/PCP, etc.
• Act as the primary point of contact for other medical specialists who are involved in the member’s care.
• Attend specialist and medical appointments with members as needed to support member attendance and understanding of appointments.
• Utilize screening tools and evidence-based practices to support member-centered care and mutual goal development. Conduct in-depth needs assessments and develop personalized care plans in collaboration with members, ensuring Strengths-Based alignment with Trauma-Informed Care (TIC) principles and Harm Reduction philosophy.
• Provide risk assessment and crisis intervention services as needed.
• Coordinate care with various providers (doctors, therapists, social workers) through in-person consultations and remote communication, prioritizing culturally competent and member-centered approaches, including developing shared treatment plans, goals and interventions.
• For members currently hospitalized, in skilled nursing, or receiving other in-patient care, collaborate with provider staff on discharge planning and advocate for in-home services such as visiting nurses, physical and occupational therapy, IHSS, etc.
• Consult and coordinate with community systems to facilitate linkage, manage referrals and advocate for member needs, with a focus on supporting identified treatment goals.
• Conduct member meetings at their home or place of choice to build rapport, assess living environment, and provide direct support to ensure safety and stability.
• Advocate for member needs, ensuring they receive appropriate, individualized, and Trauma-Informed care regardless of location or service they are receiving.
• Monitor member progress and adapt care plans as needed based on member interactions, feedback, and observations, in alignment with best practices for case management and eligibility for billing.
• Document all member interactions and services accurately and daily, ensuring authorizations, case notes, case plans, and assessments meet required standards for billing and quality service delivery.
• Using rapport, respect, and clear expectations and boundaries, de-escalate potentially volatile situations using effective communication techniques and understanding the impact of trauma and past experiences.
• Support the entire ECM/CS team with the varied complex medical needs of our members.
• Receive, assess, and incorporate feedback to personally and professionally grow.
• Assist in the development and planning of processes for the four goals of taking care of members, taking care of staff, financial sustainability, and high integrity/professional service delivery.
• Contribute to a positive and collaborative team environment, both in the office and during outreach activities, fostering inclusivity and respect for diverse experiences.
• Attend mandatory trainings on-site, online, and off-site at partner agencies for professional development to provide the highest level of service.
• Drive and manage van and shower trailer when doing outreach with other staff.
• Other duties as assigned.

Job description

Stepping Up Santa Cruz is looking for a CalAIM Nurse Case Manager to join our care coordination team in Santa Cruz. You will manage a small caseload enrolled in ECM and CS programs, perform medication reconciliation, and advocate for trauma-informed, person-centered care.

This on-site role involves collaboration with physicians, therapists, social workers, and community partners, overseeing care plans, discharge planning, and home visits.