Nurse Care Manager - ECM

Amity Foundation•Moreno Valley, CA

About The Position

The Nurse Care Manager for the Enhanced Care Management (ECM)–Community Supports (CS) program supports the delivery of high-quality clinical care to ECM Members with complex medical conditions. The role manages a caseload, primarily of Members with complex medical needs, and helps them achieve health and wellness goals through comprehensive care management and coordination. Duties include medication reconciliation, educating Members and families about chronic medical and behavioral health conditions, and collaborating with the ECM Care Team to support coordinated care and smooth transitions. The Nurse Care Manager uses evidence-based communication strategies to engage Members and promote healthy lifestyles, with the goals of improving clinical outcomes, enhancing quality of life, reducing unnecessary hospitalizations, and optimizing care delivery within the ECM framework. The position is community-based and office-based, with local travel by vehicle as needed. The work environment has moderate, sometimes loud noise, and temperatures that are usually moderate to cool but may be cold or hot. Physical demands 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 requires comfortable, office-appropriate clothing and the ability to adapt to shifting priorities and changing circumstances, work under pressure, and handle job-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, including the ability to interpret clinical data and translate findings into actionable strategies.
Willingness to travel locally as needed.
RN or LVN license.
Driver’s license.
Excellent organizational skills and attention to detail.
Excellent written and oral communication skills.
Extensive knowledge of nonprofit 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 differing perspectives and interests.
Ability to understand and appropriately apply Amity policies and procedures and adhere to agency-wide practices and regulations.
Ability to adapt to changing priorities and circumstances, work professionally under pressure, and handle mental and emotional stress related to the position.

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 when available.
Manage a caseload primarily consisting of Members with complex medical needs, particularly Tiers 1 and 2.
Engage Members and encourage their activation toward achieving health goals.
Use evidence-based communication strategies, such as Motivational Interviewing, to support collaboration, clarify shared responsibilities, resolve conflicts, and discuss 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 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.
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 education on chronic diseases, prevention, treatment, medications, and healthy living.
Coordinate smooth transitions of care, including coordination with hospitals for M1 or with 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 completion of required assessments and screenings, including the Comprehensive Health Assessment and Shared Care Plan.
Review Comprehensive Health Need Assessments completed by other care team members, sharing this responsibility with the BHCM.
Travel locally as needed to support program initiatives, trainings, and stakeholder engagement.
Comply with supervisory instructions and perform other duties or cross-training assignments as required.