RN Case Manager

Alliance TrueCare is looking for a RN Clinical Case Manager, Enhanced Care Management Program. Under limited supervision, performs duties providing intensive case management services to assigned individuals. Participates in, and supports, the planning, development, implementation, and evaluation of services under contractual and departmental requirements and guidelines.

POSITION SUMMARY
Enhanced care management is a collaborative and interdisciplinary approach to providing intensive and comprehensive care management services to populations of focus. The Enhanced Care Management program (ECM) is a new statewide Medi-Cal benefit available to eligible members with complex needs, including access to a support team that provide comprehensive care management and coordinate health and health-related care and services.
Under the general supervision of the Enhanced Care Management Department Leadership the RN Clinical position is responsible for facilitating and coordinating care management services to the network that include care coordination and facilitation activities that promotes the quality and cost of care. The position is responsible for assessing patients' needs and developing an executable plan to help patients navigate the social barriers to achieving good care, The position will work closely with Health care liaisons to ensure plan of care is executed and patient receive the right care at the right time with the right outcome and right patient experience.

The RN Clinical Case Manager efficiently oversees a diverse caseload, conducts regular telehealth meetings with patients, and collaborates closely with healthcare teams to ensure effective care coordination and regulatory compliance. They play a pivotal role in fostering strong patient relationships, managing treatment plans, and providing training on safety and quality assurance. The position will focus on the Enhanced Care Management patient population (ECM). 

DUTIES/RESPONSIBILITIES

• Work with the health centers to review utilization patterns of identified high risk patients and identify improvement plans to improve areas.
• Partner with payers to design utilization management processes to improve facility-based events (ED/IP) to ensure proper utilization and outcomes. Ensuring care is continuous and integrated among all service providers.
• Ability to develop strategies to reduce avoidable patient admissions and readmissions.
• Develop and update discharge planning including coordinating follow up care and support services to facilitate safe transition home.
• Responsible for utilizing brief medical interventions as necessary to improve the Member's ability to manage their own health.
• Develop team members and create tools to ensure strong teams and processes are in place for success.
• Meet annual goals outlined by leadership that align with the network strategic plan.
• Establish and maintain collaborative working relationships with community resources.
•  Actively participate in staff meetings and training.
• Identify at risk populations and enroll patients that need assistance with social and clinical coordination necessary to improve quality of care and control cost for patients attributed to ECM network.
• Complete comprehensive assessments on patients that have been identified for care to include a plan to specifically address including, but not limited to, physical and developmental health, mental health, dementia, SUD, LTSS, oral health, palliative care, necessary community-based and social services, and housing.
• Develop personalized care plans for each patient outlining a whole-person approach to address the services and resources needed to improve the patient's health.
• Coordinate care with health centers to ensure there is a cohesive plan to help patients achieve optimal health outcomes.
• Review payer and quality performance reports to identify the quality metrics that are performing below performance thresholds, develop, and implement clinical action plans to address gaps in care, access, and/or quality outcome issues.
• Collaborate with clinicians and key stakeholders to develop, maintain, and monitor the implementation of the care management strategies that support enhanced care management.
• Apply and teach clinical techniques for quality improvement, outcomes measurement and statistical analysis to advance quality and improve health equity of communities.
• Prepare case related reports that include clinical summary, barriers to goals, outcomes, and prognosis.
• Follow up on client referrals to ensure that clients can access and receive necessary services in a timely manner.
• Coordinate and provide care that is safe, timely, effective, efficient, equitable, and client centered.
• Manage a caseload patient ensuring that assessments and re assessments are completed timely.
• Perform other duties as assigned.

REQUIRED SKILLS/ABILITIES

• Current CA RN license. 
• Experience with Medicare and Medi-Cal environments preferred.
• Knowledge of Core Measures, HEDIS reporting, and basic statistics.
• Ability to manage multiple projects, problem-solve, and work with medical terminology.
• Proficiency in Excel, MS Office, data interpretation, and ability to learn new systems.
• Strong analytical, interpersonal, and communication skills.
• Compassionate, empathetic, and non-judgmental approach to patient care.
• Strong organizational, time management, and clinical judgment skills.
• Excellent verbal and written communication skills.
• Must have a valid driver's license and vehicle insurance. 

EDUCATION and EXPERIENCE

• Experience in a Health Care Organization or experience in Managed Care setting preferred.
• A minimum of 3 years' experience in acute care and/or ICU/CCU setting.
• Must have 2-3 years clinical experience: 3+ years preferred.
• Working knowledge of regional health disparities and social determinants of health.
• Working knowledge of Medi-Cal regulations and Enhanced Care Management.
• Must have strong interpersonal skills to work effectively internally and externally and across all levels in an organization.
• Working knowledge of relevant computer systems and software.
• Must have excellent written and verbal communication skills.
• Must possess valid driver's license, insurance, and own transportation for use in work, and be flexible with working some evenings and weekends within a 40-hour workweek.
• Must reside in San Diego County.
• Preferred certification in Case Management (e.g., CCMC or ARN).
• Bachelor's or associate degree in nursing, healthcare/business administration, or equivalent experience.
• 2-3 years of managed care or healthcare environment experience related to Case Management.

• 2-3 years of experience providing home health and/or social services case management services to low-income populations with one or more of the following: complex chronic conditions, high utilizer of emergency room and tertiary health care services, severe mental illness, and/or homelessness
• Knowledgeable and skilled in evidenced based communication such as Motivational Interviewing, or similar empathy-based communication strategies.
• Understanding of and sensitivity to multi-cultural community
• Understanding and knowledge of self-management philosophies and practices, especially as they relate to chronic medical conditions.

PHYSICAL REQUIREMENTS

• Prolonged periods sitting at a desk and working on a computer. Must be able to lift up to ten pounds at times.

WORK SCHEDULE

• Job type: Full-time
• Hours: Monday – Friday, 8:30 a.m. – 5:00 p.m.
• Location:  San Diego, CA 92123

TRAVEL

• Mileage reimbursement for the use of your vehicle is at a standard rate. Must have a valid California Driver's license and valid automobile insurance. Must reside in San Diego County.