CalAIM Nurse Case Manager

About the Organization 

Stepping Up Santa Cruz is a non-profit organization dedicated to supporting individuals with complex needs including mental health, substance use, developmental disabilities, medical vulnerability, and homelessness. We go beyond simply providing services; we empower individuals to reach their full potential by offering high-quality, individualized advocacy. We firmly believe in tailoring our support to each person's unique needs and circumstances. Our passionate team builds rapport to connect individuals with essential resources which they self-identify, ensuring they have everything they need to thrive. We believe staff’s loyalty is earned through giving them the tools to be successful and fulfilled and to reward their hard work through great pay and benefits. 

About the Position 

You'll play a vital role as the Enhanced Care Management (ECM) Nurse, part of our integrated service delivery model that takes a whole-person, team-based approach to serving members. Nurse Case Managers work with a team providing comprehensive care coordination and support to members enrolled in CalAIM’s ECM (Enhanced Care Management) and CS (Community Supports) programs. This dynamic role demands initiative, integrity, dedication, and a genuine desire to make a positive impact on people's lives. Prepare to work in a diverse environment, combining the satisfaction of fostering the growth of your team with community outreach and direct engagement with members. 

You’ll maintain a small caseload while providing critical support and guidance to ECM Case Managers. This includes assisting with member medication reconciliation and offering expertise and advocacy on healthcare-related matters to ensure members receive comprehensive and effective case management. 

Responsibilities: 

• Manage a small caseload to ensure understanding of processes and see areas for improvement. 
• Help members with complex needs get assistance by coordinating and helping to manage their care. 
• Pull outside medical records, including CCAH and SCHIO the local health information exchange (HIE), provide updates to medical care team/PCP, etc. 
• Act as the primary point of contact for other medical specialists who are involved in the member’s care. 
• Attend specialist and medical appointments with member as needed to support member attendance and understanding of appointment 
• Utilize screening tools and evidence-based practices to support member-centered care and mutual goal development.   
• Conduct in-depth needs assessments and develop personalized care plans in collaboration with members, ensuring Strengths-Based alignment with Trauma-Informed Care (TIC) principles and Harm Reduction philosophy. 
• Provide risk assessment and crisis intervention services as needed.  
• Coordinate care with various providers (doctors, therapists, social workers) through in-person consultations and remote communication, prioritizing culturally competent and member-centered approaches, including developing shared treatment plans, goals and interventions. 
• For members currently hospitalized, in skilled nursing, or receiving other in-patient care, collaborate with provider staff on discharge planning and advocate for in-home services such as visiting nurses, physical and occupational therapy, IHSS, etc.  
• Consult and coordinate with community systems to facilitate linkage, manage referrals and advocate for member needs, with a focus on supporting identified treatment goals. 
• Conduct member meetings at their home or place of choice to build rapport, assess living environment, and provide direct support to ensure safety and stability. 
• Advocate for member needs, ensuring they receive appropriate, individualized, and Trauma-Informed care regardless of location or service they are receiving. 
• Monitor member progress and adapt care plans as needed based on member interactions, feedback, and observations, in alignment with best practices for case management and eligibility for billing. 
• Document all member interactions and services accurately and daily, ensuring case notes, case plans, and assessments meet required standards for billing and quality service delivery. 
• Using rapport, respect, and clear expectations and boundaries, de-escalate potentially volatile situations using effective communication techniques and understanding the impact of trauma and past experiences. 
• Support the entire ECM/CS team with the varied complex medical needs of our members. 
• Receive, assess, and incorporate feedback to personally and professionally grow. 
• As a potential part of the management team of a new and vibrant nonprofit, assist in the development and planning of processes for the four goals of taking care of members, taking care of staff, financial sustainability, and high integrity/professional service delivery. 
• Contribute to a positive and collaborative team environment, both in the office and during outreach activities, fostering inclusivity and respect for diverse experiences. 
• Attend mandatory trainings on-site, online, and off-site at partner agencies for professional development to provide the highest level of service. 
• Other duties as assigned. 

Minimum Qualifications 

• LVN from an accredited school (RN preferred). 

• Experience in case management. 

• Valid California Driver’s License and ability to operate both personal and company vehicles. 

• Eligible to work in the US.  

• Must be 18 years of age or older.  

• Minimum two years of experience working with individuals with complex needs. 

• Reliable transportation and ability to travel within a 50-mile radius for meetings, trainings and member appointments (mileage reimbursement is provided for use of your own vehicle). 

Skills & Abilities 

• Excellent communication, interpersonal and problem-solving skills   

• Ability to complete all documentation in accordance with organizational and Medi-Cal requirements. 

• Strong Computer Literacy in Microsoft Office and Excel and Electronic Health Records (EHR) and willingness to learn other relevant software. 

• Experience working in a CalAIM ECM/CS program desired.  

• Demonstrated understanding and application of Trauma-Informed Care (TIC) principles and Harm Reduction philosophy. 

• Strong soft skills, including assessment, planning, and intervention. 

• Excellent communication and interpersonal skills to connect with members and staff from diverse backgrounds. 

• Ability to work independently and collaboratively in both office and community settings. 

• Strong organizational and time management skills to prioritize competing responsibilities and adapt to dynamic situations. 

• Strong work ethic, self-motivation, and a genuine desire to help others. 

• Must pass a relevant background check as a Medi-Cal provider upon provisional offer of employment and maintain eligibility.  

• Ability to lift up to 35 lbs occasionally. 

• Bilingual (Spanish/English and Mixteco preferred) is a plus with hourly bonus of $1.00 per hour. 

• Ability to drive a van and trailer is a plus. 

Compensation and Benefits 

• Hourly rate of $48.08 per hour with potential for performance-based pay increase after 6 months. Full time 32-hour work week, to support a healthy work-life balance. 

• Generous Paid Time Off (PTO) and Sick Leave of 4 weeks per year for relaxation and recharge. 

• An employee accrues 1 hour of PTO for every 10.4 hours worked, which is a potential 160 PTO hours per year. This works out to 20 days off for a staff member normally working a 32 hour work week. 

• Comprehensive benefits package, including no-cost health coverage with optional dental and vision coverage. 

• Company-sponsored 403(b) retirement savings plan with a generous employer match of 100% of your contributions for up to 5% of your salary. 

• Extensive training, coaching, and tools to empower you to create positive change in members’ lives and support your professional growth. 

• Opportunities for advancement.  
• Pay bonus of $1.00 per hour for bilingual English/Spanish or Mixteco. Potential for pay bonuses for relevant certifications. 

Additional Information 

• CalAIM is a new program, offering an exciting opportunity to be at the forefront of this impactful work 

• This challenging yet rewarding position allows you to directly impact members' lives through a dynamic mix of office work and community outreach. 

• If you're a passionate, driven individual with a Nursing degree, a willingness to go the extra mile, a heart for helping others, and an acknowledgment of your own self-care, this may be your dream job.

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