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.

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 and will work closely with a multi‑disciplinary care team, providing clinical support to Care Coordinators, Lead Care Managers and the entire ECM team of employees.

The role measures progress towards the goals outlined in client care plans or assessments and collaborates with a broader care team (PCP, BH clinicians, etc.) to ensure ECM enrollees receive the services outlined in their care plan.

This role requires adherence to and application of evidence‑based practices, knowledge of client and service barriers, and the provision 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!

Provides clinical oversight 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, including 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 and supports medication adherence.
• Uses data to evaluate outcomes from targeted interventions of clients and 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.
• Attends appropriate disciplined training, webinars, meetings and conferences.
• Promotes monthly Health Promotion topics/materials.
• Completes care plans and utilizes Electronic Health Record(s) (EHR) and client databases (MIS, Champ, or Health plan programs if applicable) to track and maintain accurate case notes, client, and program data in SMART Format where applicable.
• Engages 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.
• Conducts 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.

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…