RN Clinical Lead Care Manager

“Every person deserves compassion, dignity, and the safety of a place to call home.”
Homelessness is the largest social and public health crisis in California. Illumination Health + Home is a growing non-profit organization dedicated towards disrupting the cycle of homelessness by providing targeted, interdisciplinary services in our recuperative care centers, emergency shelters, housing services and children's and family programs. IF currently has 13+ facilities with 22+ micro-communities scattered across Orange County, Los Angeles County and the Inland Empire.

Job Description

The ECM Clinical Lead Care Manager is responsible for collaboration with the ECM team to serve homeless

individuals with serious mental illness, substance use disorders and/or complex medical issues. The ECM

RN/LVN will assist in addressing the social determinants of ECM smart goals. The ECM will collaborate

closely with a multi-disciplinary care team to specifically include providing clinical support to Care

Coordinators, Lead Care Managers and the entire ECM team of employees. They will measure progress

towards the goals outlined in client care plans or assessments. The ECM will collaborate with a broader

care team (PCP, BH clinicians etc.,) to ensure ECM enrollees are receiving the services outlined in the care

plan.

This is role requiring adherence to and application of evidence-based practices, knowledge of client and

service barriers as well as social determinates of health, and providence of appropriate coordination of

services to populations of focus. They help navigate health care services and systems, promote health and

preventative care, and work closely with the client’s Care Team.

The pay offered for this role is $78,000 - 84,000 Annually.
The schedule for this role is Monday - Friday, 8:30am to 5:00pm.

New graduates encouraged to apply!

Responsibilities

Provides clinical oversite to support Lead Care Managers/Care Coordinators. This includes

chronic disease management and medication monitoring.

● Engages vulnerable populations as part of a multidisciplinary outreach team. This includes

home visits, outreach to hospitals, homeless shelters and other settings, as needed.

● Provides clinical oversight and tracking of care plans.

● Participates in the review of developed patient-centered care plans and reviews any

updated care plans of all enrolled members.

● Works with hospitals to coordinate discharge plans with the behavioral health clinician,

PCP, ACO, MCO etc.

● Performs timely medication reconciliation following transitions in care. Supports medication

adherence.

● Use data to evaluate outcomes from targeted interventions of clients. Assists in developing

appropriate adjustments to care plans based on this data.

● Implements prevention & engagement activities. By presenting case conferences at scheduled

monthly/weekly meetings.

● Provides health coaching for groups of enrollees or individual enrollers as needed.

● Engages in quality improvement efforts. By participating in audits by various program administrators.

● ECM RN/LVN shall attend appropriate disciplined training, webinars, meetings and conferences.

● Promote monthly Health Promotion topics/materials.

● Complete care plans and utilize Electronic Health Record(s) (EHR) and client databases (i.e., MIS,

Champ, or Health plan programs if applicable) to track and maintain accurate case notes, client,

and program data in SMART Format where applicable.

● Engage with the Client care Team by participating in weekly Interdisciplinary Care Team meetings to

evaluate program effectiveness and client progress, while developing new strategies to address

clients' needs and enhance care plans.

● Conduct weekly and/or bi-weekly care team meetings with all relevant members of the client’s care team, in addition to monthly meetings, to review progress and coordinate care.

Expectations

Prioritize individual and client health and safety.

● Be able to meet targets and work under pressure.

● Communicate with tact and professionalism.

● Ensure confidentiality and effective management of information while maintaining

compliance with Federal and State regulations.

● Display a full understanding of problems with client flow and scheduling to improve the

efficiency of program operations.

● Demonstrate the ability to motivate staff, grasp new skills and procedures, and foster a

positive attitude towards change.

● Model openness, honesty and accountability.

● Fulfill Illumination Foundation’s Guiding Principles of Integrity, Humility, Sustainable Compassion, Quest

for Knowledge and Critical Thinking, Client-Centered Care, Innovation, Advocacy, and Stewardship

and Compliance.

● Knowledge and applied practice of HIPAA compliance.

● Adherence to Illumination Foundation’s safety policies and guidelines.

● Continued sensitivity to and awareness of cultural and linguistic diversity.

● Ability to prioritize and handle multiple complex tasks

Preferred Experience/Minimum Qualifications:

Required:

● Valid Registered Nurse (RN/LVN) license in California.

● Experience working with vulnerable populations, including people with a history of trauma, those

experiencing socioeconomic stress, homelessness, or substance use disorders.

● Strong interpersonal skills and clinical problem solving.

● Comfort working in an autonomous clinical setting and nursing in an outreach setting.

● Capability working with data to track and measure performance.

● Basic computer skills, including the ability to send and receive emails and summarize data in

spreadsheets.

● Valid CA Driver’s License and eligibility for company vehicle insurance.

Preferred:

● Bilingual in English and Spanish.

● At least 1 years of experience working with at risk/unhoused individuals

● Proficiency in Google Suite (Mail, Docs, Sheets, Calendar).

Benefits

• Medical Insurance funded by Illumination Health + Home (Kaiser and Blue Shield), depending on the plan
• Dental and Vision Insurance
• Life, AD&D and LTD Insurance funded 100% by Illumination Health + Home
• Employee Assistance Program
• Professional Development Reimbursement
• 401K with Company Matching
• 15 days' vacation PTO/year
• 6 days sick PTO/year
• 10 days holiday PTO/year
• Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans