CalAIM Nurse Case Manager

CalAIM Nurse Case Manager

Santa Cruz, California

About the Organization

Stepping Up Santa Cruzis a non-profit organization dedicated to supporting individuals with complex needsincluding mental health,substance use,developmental disabilities, medical vulnerability, and homelessness.We go beyond simply providing services; weempower individualsto reach their full potential by offeringhigh-quality, individualized advocacy.We firmly believe in tailoring our support to each person's unique needs and circumstances.Our passionate team builds rapport toconnect 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. The Nurse Case Manager works with the team providing comprehensive care coordination and supportto members enrolled in CalAIM's ECM (Enhanced Care Management) and CS (Community Supports) programs. This dynamic role demands initiative,integrity, dedication,and agenuine 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 members as needed to support member attendance and understanding of appointments.
• Utilize screening tools and evidence-based practices to support member-centered care and mutual goal development. Conductin-depth needs assessmentsand developpersonalized care plansin 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 choiceto build rapport,assess living environment,and provide direct support to ensure safety and stability.
• Advocate for member needs,ensuring they receiveappropriate, individualized, and Trauma-Informed care regardless of location or service they are receiving.
• Monitor member progress andadapt 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,ensuringauthorizations, 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 situationsusing 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.
• 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 apositive 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.
• Drive and manage van and shower trailer when doing outreach with other staff.
• Other duties as assigned.

Minimum Qualifications

Desired Skills

Compensation and Benefits

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, creed, ancestry, color, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, weight, height or other physical characteristics, marital status, veteran status, disability status, genetic information, or any other protected characteristics.

Additional Information

Stepping Up Santa Cruz will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if Stepping Up Santa Cruz is concerned about a conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.