RN Care Manager

DAP Health•Coachella, CA

7d•$44 - $47•Hybrid

About The Position

At DAP Health, we are committed to transforming lives and advancing health equity for all. As a leading nonprofit health care provider, we deliver compassionate, high-quality care to the diverse communities of the Coachella Valley and San Diego County. Our comprehensive services range from primary care to mental health, wellness programs, and beyond, with a focus on those who are most vulnerable. Joining our team means becoming part of a passionate, innovative organization dedicated to making a meaningful impact in the lives of those we serve. If you're looking for a dynamic and purpose-driven environment, we invite you to explore the opportunity to contribute to our mission. Job Summary The RN Care Manager serves as a key member of the CalAMS Enhance Care Management (ECM) program focusing on populations with complex needs. This person manages a caseload of ECM patients with complex medical and behavioral health needs, ensuring care coordination, transitions, and referrals to appropriate services. Responsibilities include overseeing health assessments, developing and monitoring shared care plans, and engaging with patients through evidence-based approaches to enhance self-management. The position also involves collaborating with interdisciplinary teams, tracking health outcomes, and providing clinical guidance to support comprehensive patient care.

Requirements

Licensed as a Registered Nurse in the State of California
Previous experience in the medical field and /or, in the Behavioral Health /Mental Health field is preferred
Current BLS certification obtained through the American Heart Association or American Red Cross
Excellent oral and written communication skills
Effective interpersonal skills with an ability to demonstrate compassion and cooperation in all situations
Ability to remain calm and rational in difficult or stressful situations
Excellent organizational skills
Accuracy is essential, close attention to detail, neatness is a priority
Ability to: Do math, organize and prioritize workload, work effectively and efficiently under stress
Supervise, multitask, understand and follow instructions
Proficiently read, write, speak and understand English
Multi-task, work independently, accurately, and with minimum supervision
Use computer, copier, fax, and assist administrative personnel as necessary
An understanding of Behavioral Health as associated with Chronic Medical Diseases preferred
Understand the Biological and Physiological nature of Mental Illness Diseases preferred
An understanding of, or ability to learn payor sources
Able to lift/move up to 40 pounds, move from place to place, and stand for long periods of time
Requires current and valid driver’s license and current personal auto insurance
Ability to travel to different locations as needed to support program and patient care needs

Nice To Haves

Bilingual in English/Spanish preferred

Responsibilities

Manage a caseload of ECM patients with complex medical and behavioral health needs
Assist members with care coordination, including transitions of care and referrals to appropriate services
Ensure completion of Health Assessments and incorporate findings into a Shared Care Plan (SCP)/Health Action Plan (HAP)
Provide clinical oversight of care plans in collaboration with the interdisciplinary care team
Engage with members both in-person and by phone using evidence-based approaches (e.g., Motivational Interviewing) to promote collaboration with their care team and enhance self-management
Provide clinical consultation to team members regarding tasks of a clinical nature
Ensure required assessments and screenings are completed, including the Comprehensive Health Assessment and Shared Care Plan
Engage with patients, approved caregivers, and care team members to implement the SCP/HAP
Review and integrate findings from Comprehensive Health Assessments (CHA) into care planning
Participate in Systematic Case Reviews and lead multidisciplinary team meetings as needed
Coordinate with internal and external health partners to support the member’s comprehensive care needs
Provide on-site and remote support for members and care team staff
Assist patients in following care plans and achieving wellness goals through ongoing engagement
Oversee and monitor patient schedules for ECM populations in collaboration with care teams
Perform regular patient screenings and vitals
Engage patients and support/encourage patient activation towards achievement of health goals
Review and sign off on medication reconciliations completed by other ECM team members, verifying accuracy and addressing any discrepancies
Collaborate with the interdisciplinary care team to resolve medication-related issues and optimize patient medication management
Educate patients and caregivers on medication regimens, potential interactions, and adherence strategies to support overall health outcomes
Utilize evidence-based communication strategies (e.g., Motivational Interviewing) to enhance patient participation and adherence
Track medical and behavioral health outcome measures in a patient registry, including but not limited to BP, BMI, HBa1C, PHQ-9, and GAD-7 scores
Use outcome measures to synthesize treatment plans for patients
Provide patient and family education about chronic medical and behavioral health conditions to improve health literacy
Gather input from other Care Management team members to prioritize patient cases for systematic population/caseload review
Provide quality care to the patients of DAP Health, within the scope of practice outlined by state or federal law
Deliver care in accordance with established standards of care and accepted community standards
Understand the organization's commitment to provide high quality integrated patient care
Promote a patient centered environment
Perform other duties as assigned