ECM Registered Nurse

St Johns Community Health•Indio, CA

About The Position

The ECM Registered Nurse Care Manager supports Enhanced Care Management (ECM) Members with complex medical needs, primarily those in Tiers 1/High and 2/Moderate acuity, by providing comprehensive care coordination and clinical support. This includes conducting medication reconciliations in collaboration with pharmacies and PCPs, promoting Member engagement and health goal achievement, and facilitating communication across the care team. The ECM RN CM uses evidence-based strategies such as Motivational Interviewing to foster collaboration, resolve conflicts, and support Member-centered care planning. Responsibilities also include tracking health outcomes, educating Members and families on chronic conditions, coordinating transitions of care, and ensuring timely completion of assessments and care plans. The RN CM plays a key role in integrating physical and behavioral health services to improve Member outcomes and health literacy. They may also serve in a lead capacity to Nurse Consultants and other health-related multidisciplinary staff; develop and evaluate program standards, policies, and procedures; and do other related work.

Requirements

Valid CA Registered Nurse license.
3-5 years' experience working as a Registered Nurse
Working knowledge of health information systems and data needed to monitor/assess utilization, performance management, and health outcomes.
Experience preparing and delivering presentations.
Extensive knowledge of development of evaluation tools, and evaluation of health programs, data analysis, and report writing.
Strong knowledge of community health evaluation tools, approaches, frameworks, and methods;

Nice To Haves

Bachelor of Science degree in nursing, medical, social work, psychology, public health, or related field preferred
Experience managing a team preferred
Bilingual English/Spanish preferred (read, write, speak)

Responsibilities

The ECM RN CM supports ECM Members with complex medical conditions and completes medication reconciliation in collaboration with pharmacy as available for all ECM-enrolled Members.
Responsible for primarily working with a caseload of Members with complex medical needs (primarily Tiers 1 and 2 – High and / or Moderate Acuity).
Engages Members and supports/encourages Member activation towards achievement of health goals.
Responsible for promoting a collaborative and effective working environment within the ECM by engaging in evidenced-based communication strategies (such as Motivational Interviewing) when discussing responsibility/sharing of tasks, effectively resolving conflicts as they arise, and collaborating on Member case discussions.
Tracks medical and behavioral health outcome measures in the web-based care management platform or internal EHR system.
Provides Member and family education about chronic medical and behavioral health conditions to improve health literacy.
Gathers input from other ECM Care Team members to prioritize Member cases for systematic population/caseload review.
Facilitates and ensures recommendations are communicated across the health care team.
Works with Members to identify health/wellness goals, and incorporates these goals into Health Action Plans/Shared Care Plan that facilitate communication among Members and Providers.
Champions healthy lifestyle changes.
Coordinates physical care management and care coordination relationships with external healthcare Providers.
Receives, identifies and follows-up treatment and medication alerts.
Consults with the ECM Care Team members about clinical concerns or questions, and provides educational training on chronic disease states, prevention, treatment, medications and healthy living.
Ensures smooth transitions of care, coordination with hospitals for M1 or with IEHP transitions of care team for M2, regarding Member admission/ discharges.
Conducts medication reconciliations with input from the Member’s PCP.
Tracks and assures required assessments and screenings are performed, including Comprehensive Health Assessment and Shared Care Plan; and Reviews Comprehensive Assessments (splits role with BHCM) upon completion by other care team members.
Other duties may be assigned or may be modified as business needs dictate.