Case Manager-RN - Brimhall CHC

Clinica Sierra Vista•Bakersfield, CA

About The Position

The Registered Nurse (RN) Case Manager (CM) provides comprehensive clinical case management. The RN CM leads and collaborates with Care Coordinators (CCs), Outreach Workers, Medical Assistants (MAs), and the interdisciplinary care team to ensure delivery of high-quality, member-centered, and cost-effective care. The RN CM is responsible for conducting comprehensive nursing assessments, developing and overseeing individualized care plans, providing condition-specific education to promote self-management, performing medication reconciliation, and delivering ongoing clinical consultation and supervision to Care Coordinators and other clinical support staff. The RN CM practices independently within the full scope of RN licensure and serves as a clinical leader.

Requirements

Graduation from an accredited School of Registered Nursing.
Current California Registered Nurse License required or Interim permit with successful completion of the RN license prior to the end of probation.
Current Basic Life Support Card issued through the American Heart Association required.
Must adhere to Clinica Sierra Vista’a employee health/immunization requirements or provide a valid exemption request for subsequent approval.

Nice To Haves

Supervisory experience preferred.

Responsibilities

Manages patient cases within the electronic health record (EHR) system.
Monitors, documents, and conducts case management activities in the patient’s EHR.
Provides clinical leadership, direction, and consultation to Care Coordinators and Outreach Workers regarding patient case management.
Ensures timely review, follow-up, and completion of provider referrals, diagnostic testing, and treatment plans.
Coordinates case management and care coordination activities with the assigned Care Coordinator, ensuring all medical needs are addressed.
Provides nursing assessment, care planning, and clinical decision-making for all co-managed cases.
Performs case management duties in accordance with RN scope of practice, and organizational policies.
Collaborates with local hospital staff—including Primary Care Providers (PCPs), Specialists, Hospitalists, and ancillary providers—on member care plans and discharge planning.
Conducts case management and care coordination activities through electronic systems, phone communication, or in-person interactions.
Conduct health assessments to identify individual needs and inform creation of member- centered care plan in collaboration with CC and other contributors to the health assessment process.
Collaborate with Pharmacy team member to ensure pharmacy needs are met.
Coordinates with Outreach Worker to ensure patients has access to services appropriate to their health needs.
Collaborates with ICT to monitor and routinely update care plan goals and interventions match patients’ motivation and priorities.
Collaborates with ICT and patients Primary Care Provider routinely on prioritization of goals.
Collaboratively initiate, present and participate in ICT conferences
Perform other duties as directed.