Complex Care RN (Specialty Populations

Marin Community Clinics•Larkspur, CA

2d•$59 - $68•Hybrid

About The Position

Marin Community Clinics, founded in 1972, is a multi-clinic network providing integrated primary care, dental, behavioral, specialty, and referral services. As a Federally Qualified Health Center (FQHC), they serve nearly 40,000 individuals annually in Marin County and have received national awards from HRSA. The Clinics are seeking a mission-driven RN to join their Complex Care team, focusing on improving health outcomes for individuals with complex medical, behavioral health, and psychosocial needs. This role will serve MCC’s most clinically complex patients, acting as a clinical liaison for BHRS/MCC’s Integrated Care Clinic and supporting MCC’s internal Enhanced Care Clinic. The Complex Care RN (specialty populations) will provide high-level clinical case management to a panel of patients and report to the Director of Complex Care.

Requirements

Associate or BA/BS degree required.
Valid California license as a registered nurse required.
1-2 years’ experience (and passion for) providing support to individuals with chronic and complex BH needs, complex medical conditions and/or substance-using individuals highly preferable.
Experience/knowledge re: CalAIM initiatives and ECM highly preferable.
Knowledge of state regulations and legal/ethical standards related to patient rights, and client/patient confidentiality required.
Must be fluent in English with the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports and business correspondence in English.
Must be able to communicate with patients and partners in Spanish: effectively present information and respond to questions from clients, customers, and the general public in Spanish.
Strong preference for a candidate than is able to conduct clinical assessment interviews and case management interventions with patients in Spanish.
To perform this job successfully, an individual must be computer literate and knowledgeable in Microsoft Office software programs, and how to conduct searches on the Internet.
Current BLS Required.
Valid Driver’s License.

Nice To Haves

Has clinical experience and expertise service complex care patients; particularly patients experiencing homelessness, trauma, and chronic medical conditions.
Has experience providing clinical supervision.
Is familiar with CalAIM, Integrated Clinic, and Enhanced Care Clinic.
Demonstrates experience/initiative in program development and improvement.
Demonstrates leadership in the field of Complex Care.
Is able to effectively give and receive feedback.
Has demonstrated excellent coalition building skills and is comfortable working with community partners including community-based organizations (CBOs), Marin County, medical/BH specialists, and insurance providers.
Has excellent organizational skills.
Is comfortable working with individuals with complex behavioral health presentations and/or substance use disorders.
Has passion for helping individuals navigate a complex system of care.
Is a team player and welcomes guidance from multidisciplinary team members.
Demonstrates initiative, creativity, and enjoys problem solving.
Ascribes to the tenets of person-centered, trauma-informed, housing-first care.
Demonstrates compassion and respect for individuals served in all interactions.
Demonstrates a willingness to be flexible and adaptable in all aspects of this work.
Training in motivational interviewing highly desired/or willingness to learn.

Responsibilities

Works closely with the Director of Complex Care to ensure the delivery of high-quality, comprehensive, person-centered case management across the department.
Point of contact/liaison for BHRS Integrated Care Clinic providers
Provides nursing support to MCC’s Enhanced Care Clinic provider (shared visits, triage, hospital follow-ups, medication management, and psychoeducation).
Carries a panel of up to 10 ECM patients co-enrolled in ECC or Integrated Clinic.
Provides clinical consultation and support to Complex Care team members.
Supports case managers and patients to navigate complex specialty care challenges.
Works closely with community partners to ensure continuity of care.
Facilitate internal and external case conferencing as needed.
Attend meetings with critical external partners.
Ensure program reporting requirements and quality measures are met.
Conduct home/community visits as needed.
Document all Patient interactions and services using MCC’s electronic health record AND secondary database.
Attend internal and external meetings (i.e., case conferencing, administrative)
Attend relevant trainings such as health coaching, engagement techniques, etc.
Timely and accurate reporting of data as requested to MCC CM programs.
May travel between clinics or meet Patients in the community as needed.
Provide frank and considered opinions regarding case management services and quality improvement measures.
Other duties may be assigned (including maintaining small caseload).