Medical - RN Case Manager - Enhanced Care Management

Medical - RN Case Manager - Enhanced Care Management (Sign-on-Bonus)

San Diego American Indian Health Center, 2630 First Avenue, San Diego, California, United States of America

Posted Tuesday, June 17, 2025 at 7:00 AM

We are an FQHC community health center dedicated to embodying the values central to American Indian cultures. This includes respect for our patients, acknowledgement of the whole person, and a focus on working together to ensure health for the individual, and therefore the community. We invite persons of all tribes, ethnic backgrounds and walks of life to experience the comprehensive care we deliver and to contribute to the services we provide for children, youth, families, adults, and elders.

The RN Case Manager for the Enhanced Care Management (ECM) program plays a critical role in improving health outcomes for Medi-Cal members with complex medical and social needs. This position is responsible for providing comprehensive, member-centered care coordination and case management services that address the clinical, behavioral, and social drivers of health. The RN Case Manager collaborates closely with internal providers, external partners, and community-based organizations to ensure continuity of care and effective resource utilization.

Primary Functions:

• Conduct comprehensive health assessments, including medical, behavioral, functional, and social determinants of health (SDOH), for each assigned ECM member.
• Develop, implement, and update individualized care plans that reflect member goals, needs, and measurable outcomes, ensuring alignment with HRSA core clinical performance measures (e.g., diabetes, hypertension, depression screening).
• Coordinate care across primary care, behavioral health, dental, substance use, housing, and specialty systems to address whole-person health needs in accordance with HRSA’s integrated services model
• Track and follow up on referrals to specialty care, housing services, substance use treatment, behavioral health, and other wraparound supports.
• Coordinate multidisciplinary team meetings and case conferences with providers, behavioral health clinicians, community health workers, and social services
• Document all case management interactions and interventions in the EHR and ECM tracking system within required time frames.
• Collaborate with the Managed Care Plan’s ECM team and CalAIM stakeholders as needed to ensure program compliance and alignment.
• Identify and resolve barriers to care, including access to transportation, medication adherence, or cultural/language needs.
• Participate in population health initiatives, quality improvement activities, and care team huddles to enhance patient outcomes and operational effectiveness
• Monitor high-risk member panels using risk stratification tools and provide appropriate intensity of services based on member acuity.
• Educate patients and families about disease prevention, chronic disease self-management, medication regimens, and navigating the healthcare system
• Maintain current knowledge of ECM program requirements, Medi-Cal managed care benefits, and community resources.
• Provide clinical oversight and mentorship to ECM community health workers and care navigators, as appropriate.
• Maintain complete, timely, and compliant documentation for all services provided, supporting HRSA grant deliverables, compliance monitoring, and managed care ECM reporting
• Respond to crises and escalating needs with urgency, de-escalation skills, and coordination with emergency or behavioral health resources.
• Participate in the annual Uniform Data System (UDS) data collection process, contributing relevant case management and clinical coordination data.
• Maintain confidentiality and comply with all HIPAA regulations and ECM program data‑sharing requirements.
• Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management.
• Assist with program evaluation, including performance measurement, member satisfaction surveys, and continuous quality improvement…