Bilingual RN Care Manager

Titanium Healthcare•Victorville, CA

8d•$80,000 - $95,000•Hybrid

About The Position

The Registered Nurse (RN) Care Manager is an essential member of Titanium Healthcare's Enhanced Care Management (ECM) interdisciplinary team. Enhanced Care Management (ECM) is a Medi-Cal benefit under California Advancing and Innovating Medi-Cal (CalAIM) that provides comprehensive, person-centered care coordination for individuals with complex medical, behavioral health, and social needs. The RN Care Manager provides comprehensive nursing care management, clinical assessment, medication reconciliation, health education, care coordination, and clinical consultation for members with complex health conditions. Working collaboratively with Behavioral Health Care Managers, Community Health Workers, Care Coordinators, Primary Care Providers, specialists, hospitals, and community partners, the RN Care Manager ensures members receive coordinated, evidence-based care that improves health outcomes and supports successful management of chronic conditions. The RN Care Manager serves as the clinical resource for the interdisciplinary care team by providing nursing expertise, supporting evidence-based interventions, facilitating transitions of care, and ensuring compliance with Department of Health Care Services (DHCS), Managed Care Plan (MCP), and Titanium Healthcare standards.

Requirements

Possess strong clinical assessment and critical thinking skills
Ability to interpret clinical information and develop appropriate nursing recommendations
Knowledge of chronic disease management and evidence-based nursing practice
Understanding of care coordination, population health, and value-based care principles
Strong understanding of medication reconciliation and transitions of care
Excellent communication, motivational interviewing, and relationship-building skills
Ability to collaborate effectively within interdisciplinary teams
Strong organizational, documentation, and time management skills
Ability to prioritize multiple competing responsibilities in a fast-paced environment
Commitment to delivering compassionate, culturally competent, person-centered care
Fluent in English (written and verbal), Bilingual in Spanish
Ability to communicate clearly in-person, by phone, and electronically
Adequate hearing and vision (with corrective devices if necessary) to conduct assessments and documentation
Ability to identify problems and use logic and related information to develop and implement solutions
Commitment to maintaining patient confidentiality and adhering to ethical standards in healthcare practice
Ability to lift, carry, push, or pull up to 20–25 pounds (e.g., laptop bag, forms, mobile equipment)
Ability to climb stairs or navigate uneven terrain in community and home environments
Ability to bend, reach, and conduct in-person visits in non-traditional environments
Must be able to remain in a stationary position
Must be able to move around the office and/or travel throughout community
Ability to operate a vehicle and travel to meet with members around the community; attend meetings and events as required or requested
Work may occur in homes, shelters, outdoor settings, hospitals, or community organizations, which may include exposure to pets, smoke, odors, clutter or unsanitary condition, and varying temperature conditions
Ability to maintain professionalism and safety in diverse environments
Ability to work independently and carry out assignments to completion within the parameters of established policies and procedures
Frequent use of computers, keyboard, and handheld/mobile devices
Ability to type for extended periods
Competent with computers, email, virtual platforms, electronic health records (EHRs), Microsoft Office based programs, and virtual communication platforms
Ability to accurately document clinical information within electronic care management systems
Comfortable utilizing multiple technology platforms simultaneously in a remote work environment
Associate’s degree in nursing (ADN) from an accredited nursing program
Minimum 1+ years of RN experience in acute care, ambulatory care, managed care, case management, population health, or a related clinical setting
Active, unrestricted California Registered Nurse license
Experience using an Electronic Health Record (EHR)
Distraction-free home workspace with a secure internet connection

Nice To Haves

Bachelor's degree in nursing (BSN)
Experience in Enhanced Care Management (ECM), Complex Case Management, Population Health, or Care Coordination
Experience working with California Medi-Cal Managed Care Plans
Experience using eClinicalWorks (eCW)
Experience conducting medication reconciliation and Transitional Care Management
Certified Case Manager (CCM) certification
Current American Heart Association Basic Life Support (BLS) certification
Current CPR certification

Responsibilities

Manage a caseload of ECM members with complex medical needs, primarily Tier 1 and Tier 2 members, using a person-centered approach
Conduct telephonic and face-to-face member visits based on member acuity, risk level, and Managed Care Plan requirements
Perform comprehensive nursing assessments to identify clinical needs, barriers to care, and opportunities to improve health outcomes
Engage members using motivational interviewing and evidence-based communication techniques to encourage active participation in their healthcare and achievement of personal health goals
Promote healthy lifestyle changes and self-management of chronic medical and behavioral health conditions
Provide individualized health education related to chronic disease management, medications, preventive care, and wellness
Coordinate care across primary care providers, specialists, behavioral health providers, hospitals, skilled nursing facilities, pharmacies, and community organizations
Facilitate timely access to medical, behavioral health, and community-based services
Develop, implement, monitor, and update individualized Care Plans that reflect member-centered goals
Ensure recommendations are communicated effectively across healthcare providers and care team members
Coordinate physical health care management and care coordination activities with external healthcare providers
Complete medication reconciliation for ECM members following hospitalizations, emergency department visits, transitions of care, medication changes, and other clinically appropriate encounters
Collaborate with the member's Primary Care Provider and pharmacy to ensure medication accuracy and promote medication adherence
Monitor medication alerts, treatment plans, and clinical notifications, ensuring appropriate follow-up
Review Comprehensive Health Assessments (CHA)
Track and ensure completion of required assessments, screenings, Shared Care Plans, and documentation required by Managed Care Plans and DHCS
Monitor medical and behavioral health outcome measures using the organization's care management platform
Identify members requiring clinical intervention or escalation and collaborate with providers to address complex clinical needs
Ensure smooth transitions of care following emergency department visits, hospital admissions, skilled nursing facility stays, and other care transitions
Coordinate discharge planning activities and facilitate timely follow-up appointments with Primary Care Providers and specialists
Collaborate with hospitals, facilities, providers, and interdisciplinary team members to reduce avoidable readmissions and improve continuity of care
Serve as the clinical resource for Behavioral Health Care Managers, Community Health Workers, Care Coordinators, and other interdisciplinary team members
Provide consultation regarding chronic disease management, medications, treatment plans, prevention strategies, and evidence-based nursing interventions
Support interdisciplinary discussions involving complex member cases and clinical decision-making
Participate in Systematic Case Reviews (SCR), interdisciplinary case conferences, and ad hoc clinical case reviews
Foster a collaborative, respectful, and effective team environment through evidence-based communication and conflict resolution strategies
Collaborate with providers and care team members to improve member outcomes and ensure high-quality, coordinated care
Maintain accurate, timely, and compliant documentation within the electronic health record and care management platform
Ensure compliance with Titanium Healthcare policies, DHCS regulations, Managed Care Plan requirements, and CalAIM ECM standards
Participate in quality improvement initiatives, ongoing education, and organizational training
Perform additional duties and special projects as assigned

Benefits

12 holidays
up to 15 days of accrued PTO
additional time for sick, jury duty, bereavement, reproductive loss, and therapy
Medical, Dental, & Vision Benefits
unlimited therapy sessions funded 100% by Titanium Healthcare
Flexible Spending, Health Savings & Dependent Care Accounts
Life/AD&D insurance funded 100% by Titanium Healthcare
Supplemental Short-Term Disability
Employee Assistance Programs
Pet Insurance
401(k) plan