Nurse Care Manager - ECM

Amity Foundation•Moreno Valley, CA

20h•$70,000 - $75,000

About The Position

The Nurse Care Manager for the Enhanced Care Management (ECM) - Community Supports (CS) program supports high-quality clinical care for ECM Members with complex medical conditions. The role manages a caseload, primarily Members with complex medical needs, and helps ensure that their health and wellness goals are met through comprehensive care management and coordination. Responsibilities include medication reconciliation, Member and family education on chronic medical and behavioral health conditions, and collaboration with the ECM Care Team to support smooth transitions of care. The Nurse Care Manager uses evidence-based communication strategies to engage Members and promote healthy lifestyles, with the goal of improving clinical outcomes, enhancing quality of life, reducing unnecessary hospitalizations, and optimizing care delivery within the ECM framework. The position is based in community and office settings and may require local travel by vehicle to support program initiatives, trainings, and stakeholder engagement. Physical requirements include frequently lifting or moving up to 50 pounds; sitting, standing, typing, and communicating for extended periods; and occasionally reaching, walking, climbing, pulling, pushing, grasping, stretching, and stooping. The role involves adapting to shifting priorities and changing circumstances and handling work-related mental and emotional stress.

Requirements

Registered Nurse (RN) or Licensed Vocational Nurse (LVN) with the California Board of Registered Nursing.
At least 5 years of nursing experience, including at least 2 years in care management, population health, or a related field.
Expert knowledge of healthcare practices, care coordination, and patient-centered care.
Strong analytical skills and ability to interpret clinical data and translate findings into actionable strategies.
Willingness to travel locally as needed for program initiatives, trainings, and stakeholder engagement.
Excellent organizational skills and attention to detail.
Excellent written and oral communication skills.
Extensive knowledge of non-profit organizations.
Proficiency in Microsoft Office Suite or similar software.
Knowledge of the contracting process and associated local, state, federal, and other regulations.
Ability to multitask, identify problems, provide recommendations to management teams, and implement applicable systems.
Ability to work constructively with diverse people and parties with divergent perspectives and interests.
Ability to understand and appropriately apply Amity policies and procedures and adhere to agency-wide practices and regulations.
Valid driver’s license.
Ability to adapt as priorities shift and circumstances change, work professionally under pressure, and handle mental and emotional stress related to the position.
Ability to meet physical requirements, including frequently lifting or moving up to 50 pounds and sitting, standing, and typing for extended periods.

Nice To Haves

Previous clinical experience working with individuals recently released from jail or prison.
Previous supervisory experience.

Responsibilities

Support ECM Members with complex medical conditions and complete medication reconciliation in collaboration with pharmacy, as available, for all ECM-enrolled Members.
Manage a caseload primarily consisting of Members with complex medical needs, particularly Tiers 1 and 2.
Engage Members and encourage Member activation toward achievement of health goals.
Promote a collaborative and effective working environment within ECM using evidence-based communication strategies, including Motivational Interviewing, to discuss task responsibilities, resolve conflicts, and collaborate on Member cases.
Track medical and behavioral health outcome measures in a web-based care management platform or equivalent.
Educate Members and families about chronic medical and behavioral health conditions to improve health literacy.
Gather input from ECM Care Team members to prioritize Member cases for systematic population and caseload review.
Facilitate communication of recommendations across the healthcare team.
Work with Members to identify health and wellness goals and incorporate them into Health Action Plans or Shared Care Plans that facilitate communication among Members and Providers.
Promote healthy lifestyle changes.
Coordinate physical care management and care coordination relationships with external healthcare Providers.
Receive, identify, and follow up on treatment and medication alerts.
Consult with ECM Care Team members about clinical concerns or questions and provide educational training on chronic disease states, prevention, treatment, medications, and healthy living.
Ensure smooth transitions of care and coordinate with hospitals for M1 or the IEHP transitions of care team for M2 regarding Member admissions and discharges.
Conduct medication reconciliations with input from the Member’s PCP.
Track and ensure required assessments and screenings are performed, including the Comprehensive Health Assessment and Shared Care Plan.
Review Comprehensive Health Need Assessments, sharing this role with the BHCM, after completion by other care team members.
Comply with supervisory instructions and perform other job duties, responsibilities, and assignments required by company officials; cross-training in other functions may be included.