Registered Nurse (RN) - Enhanced Care Management (ECM) at Integrated Practice Management LLC

Bakersfield, California, United States -

Full Time

Start Date

Immediate

Expiry Date

09 Jun, 26

Salary

0.0

Posted On

11 Mar, 26

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Registered Nurse, Care Coordination, Clinical Oversight, Patient Assessment, Risk Identification, Patient Education, Chronic Disease Management, Behavioral Health, Social Determinants of Health, Interdisciplinary Care Team, Medication Reconciliation, Healthcare Systems, Community Resources, Documentation, Organizational Skills, Cultural Sensitivity

Industry

Description

Description Program Overview Enhanced Care Management (ECM) is designed to provide comprehensive, coordinated care to Medi-Cal beneficiaries with complex medical and social needs, including individuals with behavioral health needs, homelessness, or high utilization of healthcare services. The program focuses on improving health outcomes through a person-centered, team-based approach that integrates medical care coordination, behavioral health support, and interventions addressing social determinants of health. Job Description The ECM Registered Nurse (RN) provides clinical oversight, consultation, and medical care coordination within the ECM program to support patients with complex healthcare needs. The RN serves as a clinical resource to non-clinical Lead Care Managers (Case Managers) and other ECM team members to ensure the delivery of safe, high-quality, and coordinated care in compliance with ECM program requirements and contractual obligations. The RN supports the development and implementation of individualized care plans and collaborates with the patient’s Interdisciplinary Care Team (ICT), including primary care providers, specialists, behavioral health providers, hospitals, and community-based organizations. Through clinical assessment, risk identification, care coordination, and patient education, the RN helps address medical needs, improve health outcomes, and reduce avoidable emergency department visits and hospitalizations. Requirements Clinical Oversight Provide clinical oversight and consultation to non-clinical Care Managers and ECM staff regarding patient medical needs, care coordination strategies, and clinical risk factors. Serve as a clinical resource to the ECM care team regarding chronic disease management, treatment plans, and symptom monitoring. Assist staff in identifying clinical red flags, escalating urgent medical concerns, and coordinating timely intervention when necessary. Participate in Interdisciplinary Care Team (ICT) meetings to provide clinical insight, risk assessment, and recommendations to support coordinated, whole-person care. Care Plan Development and Management Support the development and review of individualized care plans to ensure appropriate clinical goals, interventions, and medical care coordination activities are included. Ensure care plans reflect patient priorities, clinical needs, and social determinants of health. Monitor care plan implementation and provide recommendations when adjustments are needed to improve patient outcomes. Assist with identifying barriers to care, including medication adherence, access to specialty care, or gaps in follow-up. Care Coordination Collaborate with care managers, providers, hospitals, and community partners to coordinate medical services and ensure appropriate referrals and access to supportive services. Support transitions of care following emergency department visits, hospitalizations, or other significant healthcare events. Assist with medication reconciliation and patient understanding of medication regimens when appropriate. Identify high-risk patients who may benefit from enhanced monitoring, additional care coordination, or escalation to providers. Recognize and help address non-clinical barriers that impact patient health outcomes, including social determinants of health such as housing instability, food insecurity, transportation challenges, and access to community resources. Training and Staff Support Provide clinical training and education to ECM staff on relevant medical conditions, clinical warning signs, care coordination best practices, and healthcare system navigation. Serve as a resource to staff when complex clinical questions arise. Collaboration Work collaboratively with ECM administrators, care managers, providers, behavioral health professionals, and community partners. Maintain effective communication with internal and external partners to facilitate comprehensive patient care. Quality Assurance and Program Performance Participate in quality assurance activities including chart reviews and documentation monitoring. Provide recommendations to improve program performance, patient engagement, and quality outcomes. Participate in quality improvement initiatives as assigned. Cultural Sensitivity Demonstrate sensitivity to the cultural, linguistic, and socioeconomic characteristics of the service population and incorporate culturally responsive care practices. Safety and Compliance Adhere to professional nursing standards and regulations established by the California Board of Registered Nursing. Follow all organizational policies, procedures, and legal mandates, including HIPAA, patient confidentiality, releases of information, protected health information (PHI), and medical record requirements. Ensure clinical activities align with ECM program guidelines and applicable regulatory standards. Education and Qualifications Current and unrestricted Registered Nurse (RN) license in the state of California. Experience and Skills Minimum of two (2) years of clinical nursing experience in a healthcare setting. Experience with care coordination, case management, or population health programs preferred. Experience working with high-risk or medically complex populations, including individuals with chronic conditions, behavioral health needs, or social barriers to care. Strong understanding of healthcare systems, community resources, and interdisciplinary care coordination. Excellent communication, documentation, and organizational skills.

Responsibilities

The Registered Nurse (RN) provides clinical oversight and medical care coordination within the Enhanced Care Management (ECM) program for Medi-Cal beneficiaries with complex needs. The RN acts as a clinical resource to care managers, supporting the development of individualized care plans and collaborating with interdisciplinary teams to improve patient health outcomes.