RN Care Manager - Temporary

Institute on Aging•Inland Empire, CA

12d

About The Position

IOA’s Community Living Services division provides care management for seniors and adults with disabilities who are at risk of nursing home or institutional placement. The HCBA Medi-Cal Waiver program’s multidisciplinary care team coordinates Waiver and State Plan services and connects participants with long-term services and supports in their communities. Services are delivered in participants’ community-based residences. The Temporary, full-time Care Manager/Registered Nurse provides temporary coverage for a leave of absence. The assignment is slated to end no earlier than December 1, 2026, depending on business needs. The RN conducts comprehensive nursing assessments of participants’ medical needs, functional and cognitive abilities, and environmental and social needs to determine the services needed to support their preferences and community living. The role requires driving throughout Riverside and San Bernardino Counties, depending on the assigned area, with occasional cases outside the region.

Requirements

Current, unencumbered license to practice as an RN in California.
Current Basic Life Support (BLS) certification.
Meet at least one of the following experience pathways: at least 1,000 hours in the previous two years in an acute care hospital caring for individuals with care needs at levels specified in the waiver; at least 2,000 hours in the previous three years in an acute care hospital caring for individuals with those care needs; at least 2,000 hours in the previous five years working for a licensed and certified home health agency caring for individuals with those care needs; or at least 2,000 hours in the previous five years in another area that, in DHCS’s opinion, demonstrates appropriate knowledge, skill, and ability to care for individuals at one or more specified levels of care.
Experience establishing short- and long-range patient care goals that contribute to a continuum-of-care focus and delivering quality care through the professional nursing process.
Experience with and understanding of medical diagnoses and medications associated with functionally impaired adults and older adults.
Exceptional communication and presentation skills when working with functionally impaired adults and older adults, their support systems, and health professional teams.
Demonstrated case management experience and skills within the community health care delivery system.
Excellent attention to detail and problem-solving skills.
Demonstrated ability to prioritize multiple critical tasks.
Excellent computer literacy.
Valid driver’s license and proof of insurance.
Willingness to travel in Riverside and/or San Bernardino Counties.

Nice To Haves

Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders.
Exceptional interpersonal, oral, and written communication skills.

Responsibilities

Document assessments, case notes, care coordination, and utilization management in MedCompass population health management software.
Work with participants, their legal representatives, support networks, and primary care physicians to develop goals based on assessed needs, circumstances, and preferences.
Develop Plans of Treatment (POTs) to mitigate risk and minimize service disruptions.
Identify services available through friends, family, or publicly funded programs.
Implement POTs by identifying service providers and community resources to support timely, effective, and efficient mobilization and allocation of services.
Identify and, when necessary, train backup caregivers willing and able to provide unpaid support when scheduled Waiver service providers do not arrive.
Provide information, education, counseling, and advocacy to and on behalf of participants.
Establish a care coordination schedule based on participant needs and acuity, as determined by initial assessments and subsequent reassessments.
Monitor delivery of HCBA Waiver services to confirm that participants receive services authorized in their POTs.
Monitor authorized service quality through ongoing contact, including a monthly face-to-face visit or telephone call, to check changes in health, mood, social integration, functionality, and overall well-being.
Conduct annual face-to-face visits, reassessments, and care plan updates.
Follow up with participants after Emergency Department visits and inpatient facility admissions.
Perform other duties as assigned.