Enhanced Case Manager Nurse (Bilingual)

Santa Cruz Community Health•Santa Cruz, CA

20d•$79,040 - $98,072•Hybrid

About The Position

Santa Cruz Community Health (SCCH) is a multi-site, Federally Qualified Health Center (FQHC) serving Santa Cruz County residents. SCCH began as a women's health collective in 1974 with the mission to improve the health of our patients and the community and advocate the feminist goals of social, political, and economic equality. Now, 50 years later, we serve that same mission at our three clinic sites: the Santa Cruz Women's Health Center in downtown Santa Cruz serving women and children; the Live Oak Health Center serving everyone; and the Santa Cruz Mountain Health Center providing appropriate and expanded access to care for our patients in the San Lorenzo Valley. Driven by our commitment to health care as a human right, SCCH is a leading non-profit provider offering comprehensive health services to our patients, regardless of their ability to pay. We have been recognized in the community as a leader in delivering high-quality, innovative care, and we are active in local, state, and national advocacy work that empowers our patients and community to be healthy, happy, and successful. SCCH has a diverse patient population and an engaging and friendly work environment. Our caring and committed staff works as a team to fulfill our mission so that all our patients have access to quality, whole-person health care. POSITION SUMMARY: The Enhanced Case Management (ECM) Nurse is a vital member of Santa Cruz Community Health’s integrated delivery model that takes a whole-person, team-based approach to serving patients. Case Manager Nurse’s undertake a collaborative process of assessment, treatment-planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs.

Requirements

LVN from an accredited school or another nursing degree (such as RN)
Experience in case management
Excellent communication, interpersonal and problem-solving skills
Ability to work independently and collaboratively in a primary care setting
Ability to complete all documentation in accordance with organizational requirements
Strong Computer Literacy in Microsoft Office and Excel
Reliable transportation and ability to travel within a 50-mile radius for meetings, trainings and patient appointments (mileage reimbursement is provided – your own vehicle)

Nice To Haves

Case management/patient navigation experience within a community-based health center
Bilingual in English/Spanish Required
Knowledge of evidence-based practices including: Motivational Interviewing, Harm Reduction and Trauma-Informed Care
Ability to work in a fast-paced environment with quickly shifting priorities
Experience with Electronic Health Records

Responsibilities

Supports the entire Enhanced Case Management (ECM) team with the varied complex medical needs of our ECM patient population.
In concert with patients’ Care Teams, especially with the Care Team RNs, and in keeping with established post-hospital discharge policies and procedures, follows up with all patients open to CM who have recently been hospitalized. Collaborate with hospital and skilled nursing facility staff on discharge planning. Advocates for in-home services such as visiting nurses, physical therapy, etc.
Manages a small panel of assigned patients who have complex medical needs and meet criteria for ECM services. Please see below for a description of patient populations served. These are subject to change as rules and regulations change.
Helps Central California Alliance for Health (CCAH) members with complex needs get assistance by coordinating and helping to manage their care for a designated period of time.
Pulls outside records, checks the health information exchange (HIE), provides updates to medical care team/PCP in alignment with post-hospital discharge and medical records policies and procedures.
Acts as the primary point of contact for other medical specialists who are involved in the ECM patient’s care.
May attend specialist and medical appointments as needed.
Utilizes screening tools and evidence-based practices to support patient-centered care and mutual goal development and communicates findings to the appropriate licensed Care Team member.
Collaborates with Care Team members to co-design and implement care plans that improve the patient experience, improve health outcomes, and reduce barriers to care. Provides relevant input into care plans for other ECM patients who may not be assigned to the ECM Nurse.
Provides risk assessment and crisis intervention services as needed and communicates findings to the appropriate licensed Care Team member.
Consults and collaborates with members of the patient’s care team on developing shared treatment plans, goals, and interventions.
Consults and coordinates with community systems to facilitate linkage, manage referrals and advocate for patient needs, with a focus on supporting identified treatment goals.
Maintains patient and program documentation according to HIPAA and SCCH standards and regulations.
Utilizes Health Information Technology such as Serving Communities Health Information Organization (SCHIO), the CCAH portal, and Unite Us to better serve patients and improve communication with outside agencies.
Uses critical thinking and common sense to analyze situations, make timely and valid decisions, and take appropriate actions. Must be prepared to adapt to rapidly shifting priorities with grace.
Expands the interdisciplinary team to include patients, their identified support system, health care providers and community-based professionals with whom the client interacts (e.g. nurses, substance use counselors, behavioral health providers, pharmacy, etc.)
Works within scope of practice and maintains a high level of ethical standards regarding confidentiality, dual-relationships and professional stature.
Practices cultural humility in working with diverse patient populations.
Attends community meetings as assigned and represents the organization professionally and capably.
The ECM Nurse will provide support to all our identified case management populations (subject to change): Adults over 18 and youth, patients with multiple chronic health conditions, behavioral health diagnoses, barriers to care, limited access to resources, unstable housing and other complex factors. Children and youth with a California Children’s Services (CCS) diagnosis; children and youth with Child Welfare (CWS) involvement; children and youth with housing instability. Adults, children and youth with substance use disorder either active or in recovery, motivation toward treatment. Adults and youth in their perinatal period or pregnancy who meet other ECM criteria (e.g. housing instability, substance use disorder, etc.)