CalAIM Nurse Case Manager

Job Description

Job Description

About the Organization

Stepping Up Santa Cruz is a non-profit organization dedicated to supporting individuals with complex needs including mental health, substance use, developmental disabilities, medical vulnerability, and homelessness. We go beyond simply providing services; we empower individuals to reach their full potential by offering high-quality, individualized advocacy. We firmly believe in tailoring our support to each person's unique needs and circumstances. Our passionate team builds rapport to connect 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. Nurse Case Managers work with a team providing comprehensive care coordination and support to members enrolled in CalAIM’s ECM (Enhanced Care Management) and CS (Community Supports) programs. This dynamic role demands initiative, integrity, dedication, and a genuine 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 member as needed to support member attendance and understanding of appointment
• Utilize screening tools and evidence-based practices to support member-centered care and mutual goal development.
• Conduct in-depth needs assessments and develop personalized care plans in 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 choice to build rapport, assess living environment, and provide direct support to ensure safety and stability.
• Advocate for member needs, ensuring they receive appropriate, individualized, and Trauma-Informed care regardless of location or service they are receiving.
• Monitor member progress and adapt 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, ensuring 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 situations using 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.
• As a potential part of the management team of a new and vibrant nonprofit, 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 a positive 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.
• Other duties as assigned.

Minimum Qualifications

Skills & Abilities

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

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