The Nurse Case Manager position will review chronic condition patients and assist in the development of care plans in collaboration with care coordinators, primary care providers, and other supportive clinical staff. This position will work with clinic office manager, supervisors, and will be the lead to conduct annual competency assessments of Medical Assistants across organization. Additionally, this position will also oversee vaccine management and compliance. 

The Nurse Case Manager will collaborate closely with a multidisciplinary care team, including providing clinical support to medical assistants, EMTs, and LVNs on the medical coordination team and case management staff. The RN Case Manager will collaborate with the broader care team (PCP, BH clinicians, etc.) to ensure that the enrollees are receiving needed services and measuring progress towards the goals outlined in their patient-centered care plan.

Responsibilities

• Provides clinical support to case managers/medical coordinators. This includes chronic disease management and medication monitoring.
• Providing a bridge between the medical coordination staff and case management to create a more comprehensive care structure and providing guidance on appropriate external resources
• Provides clinical oversight and tracking for comprehensive intake assessments.
• Participates in developing patient-centered care plans for the enrollees on their panel.
• Performs timely medication reconciliation following transitions in care. Supports medication adherence and education.
• Develops and implements new programs to provide more resources to clients, connecting with community-based organizations to develop new partnerships and determine creative ways to address client needs while in Recuperative Care and/or Short-Term Post-Hospitalization
• Uses data to evaluate outcomes from targeted interventions. Assists in developing appropriate adjustments to care plans based on this data.
• Implements prevention & engagement activities.
• Provides health coaching for groups of enrollees or individual enrollees as needed.
• Engages in quality improvement efforts.

Preferred Experience/ Minimum Qualifications

Required:

• Valid Registered Nurse (RN) license in California
• Experience working with vulnerable populations, including persons with a history of trauma, those experiencing socioeconomic stress, homelessness, or substance use disorders
• Strong interpersonal skills and clinical problem solving
• Comfort working in an autonomous clinical setting and nursing in an outreach setting
• Capability working with data to track and measure performance
• Basic computer skills, including the ability to send and receive emails and summarize data in spreadsheets.
• Valid CA Driver’s License and eligibility for company vehicle insurance.

Preferred:

• Bachelor of Science in Nursing
• Care Management experience
• Bilingual in English and Spanish.
• Proficiency in Microsoft Office Suite (Outlook, Word, Excel, Teams).

Families Together of Orange County (FTOC) is proud to be an equal opportunity employer. FTOC does not discriminate based on race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, disability, ancestry, marital status, veteran status, medical condition, or any protected category prohibited by local, state or federal laws.