Registered Nurse Care Manager (RN)

“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 Foundation (IF) 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.

Job Description:

The Registered Nurse Care Manager is responsible for assessing clients for recuperative care from the point
of referral, identifying clinical and social needs and assisting with transition to the recuperative care setting.
Once the client has been admitted to recuperative care, the RN Care Manager will be responsible for providing
clinical oversight, promoting medication adherence and follow-up with primary care, behavioral health, and
other specialists, and providing medical education to improve client independence with managing chronic
conditions. The Nurse Care 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.

Tasks/Responsibilities:

● Provides support to the referral team to determine which clients are a good fit for Recuperative Care
and Short-Term Post-Hospitalization programs
● 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.
● Works with hospitals to coordinate hospital admission/discharge plans with the behavioral health
clinician, PCP, ACO, MCO, etc.
● 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.
The preceding functions have been provided as examples of the types of work performed by employees assigned to this job classification. Management reserves the right to add, modify, change or rescind the work assignments of different positions and to make reasonable accommodations so that qualified employees can perform the essential functions of the job.

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 Google Suite (Mail, Docs, Sheets, Calendar).
The above statements are intended to describe the general nature and level of work being performed by the incumbent(s)
of this job. They are not intended to be an exhaustive list of all responsibilities and activities required of the position.