Registered Nurse (RN) Community Care & Enhanced Care Management (ECM)

Registered Nurse (RN)

• Community Care & Enhanced Care Management (ECM) Redding, CA 96001 $120,000
• $150,000 a year
• Full-time $120,000
• $150,000 a year

•

Full-time About Us:

We are a dedicated community services organization committed to breaking the cycle of homelessness. Operating across three counties, we provide a compassionate bridge from life on the streets to the stability of a permanent home. Our mission is to meet individuals exactly where they are, offering a path forward through intensive support, resource navigation, and unwavering advocacy. Specific job duties and responsibilities are subject to change depending on client needs.

Department :

CalAIM Clinical Services Reports to: Clinical Director /

Program Manager FLSA Status:

Full-Time, Non-Exempt Location:

Field-Based / Hybrid (Serving Shasta County, Humboldt County, Butte County.) Role Overview The Enhanced Care Management (ECM) Registered Nurse (RN) delivers whole-person, community-based care coordination to Medi-Cal members with complex medical, behavioral, and social needs. Operating under California's CalAIM initiative, our organization contracts with Partnership HealthPlan of California and DHCS to provide representative, multi-disciplinary care directly to vulnerable populations where they live. The ECM RN blends advanced clinical assessment, intensive case management, and advocacy to help members navigate the healthcare system, stabilize chronic conditions, and address vital social determinants of health (SDOH). Key Responsibilities 1. Direct Field-Based Clinical Care & Assessment Conduct face-to-face, culturally competent health assessments in members, shelters, or community locations to assess clinical stability, cognitive status, and immediate physical needs. Formulate and manage comprehensive, member-centered individual care plans (ICPs) prioritizing the member's voice and representative preferences. Perform comprehensive medication reconciliation and education, particularly following acute hospital or skilled nursing facility (SNF) discharges, and Mental Health to prevent readmissions. Deliver trauma-informed disease management education (e.g., diabetes, severe hypertension, substance use disorders) to improve member self-efficacy. 2. Multi-Disciplinary Care Coordination & Navigation Serve as the primary clinical liaison between the members, Primary Care Providers (PCPs), specialists, behavioral health teams, and Partnership HealthPlan representatives. Facilitate seamless Transitions of Care by actively managing hospital/SNF discharges and ensuring immediate follow-up appointments and home services are arranged. Coordinate directly with internal and external partners to link members to vital CalAIM Community Supports (e.g., housing transition/navigation, Recuperative Care. Accompany high-risk members to critical medical appointments when necessary to advocate, translate complex terms, and ensure follow-through on treatment plans. 3. Compliance, Documentation & Quality Assurance Maintain accurate, daily electronic health record (EHR) documentation of all members face-to-face visits, care coordination, and billing metrics in strict accordance with DHCS and Partnership HealthPlan compliance guidelines. Participate regularly in Interdisciplinary Care Team (ICT) meetings and complex case reviews. Utilize data-driven metrics to track health outcomes and modify member care plans dynamically based on changing needs. Required Qualifications License & Education Active, unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing (BRN). Current BLS/CPR certification. Associate Degree in Nursing (ADN) required; Bachelor of Science in Nursing (BSN) preferred. Experience & Attributes Minimum 2 years of experience in community health, home health, public health, emergency medicine, or intensive case management. Deep knowledge of CalAIM framework , Medi-Cal managed care systems, and the target populations of focus (e.g., individuals experiencing homelessness, justice-involved, severe mental illness preferred.) Demonstrated commitment to principles of Harm Reduction , Trauma-Informed Care , and cultural humility.

• This is an in-person job, remote/virtual is not an option

•

Job Type:

Full-time Pay:

$120,000.00

• $150,000.

00 per year

Benefits:

401(k) Dental insurance Health insurance Life insurance Vision insurance

Education:

Bachelor's (Preferred)

Experience:

Intensive case management: 2 years (Preferred)

License/Certification:

California RN License (Required)

Work Location:

In person