Registered Nurse - Clinical Case Consultant (CalAIM ECM Program) Santa Clara

Location: Santa Clara County
Employment Type: Full-Time
Reports To: Clinical Program Manager / ECM Director
Salary Range: $85,000 – $95,000 Annually

At Pacific Health Group, we believe that every Californian deserves access to compassionate, coordinated, and person-centered care. As a Registered Nurse – Clinical Case Consultant in our CalAIM Enhanced Care Management (ECM) program, you will be a catalyst for better health outcomes among the state’s most vulnerable populations—those experiencing homelessness, living with serious mental illness (SMI), substance use disorders (SUD), or multiple chronic conditions.

You will serve as the clinical cornerstone of a multidisciplinary team, ensuring that every care plan is clinically sound, culturally responsive, and designed to help members live healthier, more stable lives.

Key Responsibilities

Clinical Leadership & Guidance

• Provide clinical oversight to ECM Care Coordinators, Community Health Workers (CHWs), and Case Managers.
• Conduct case consultations to ensure care plans are safe, evidence-based, and aligned with each member’s goals.
• Participate in interdisciplinary case rounds to support integrated decision-making and problem-solving.
• Offer clinical insight on risk assessments, screenings, and care prioritization.

Impact Example:
By identifying medication risks in a member with both diabetes and schizophrenia, you ensure the team delivers safe, coordinated care that improves both physical and mental health outcomes.

Care Coordination Excellence

• Support seamless transitions of care from hospital to home or community-based settings.
• Collaborate with providers, health plans, behavioral health agencies, and community organizations to bridge service gaps.
• Proactively identify members at risk for adverse outcomes and guide timely interventions.

Impact Example:
You connect a recently discharged member with their primary care provider, ensure medication access, and coordinate in-home support—reducing the likelihood of readmission.

Documentation & Compliance

• Maintain accurate, timely documentation of clinical reviews, recommendations, and member interactions in the EHR.
• Review care team documentation to ensure compliance with Medi-Cal ECM standards and audit readiness.
• Promote accountability and data integrity across the team.

Impact Example:
Your diligence ensures that care plans meet ECM requirements while reflecting each member’s voice, goals, and progress.

Training & Team Development

• Lead trainings for non-clinical staff on chronic disease management, medication safety, and symptom recognition.
• Mentor care team members, fostering confidence and clinical understanding in the field.

Impact Example:
By teaching CHWs to recognize early signs of diabetic crises, you empower frontline staff to prevent emergencies and save lives.

Quality Improvement & Program Innovation

• Analyze outcomes to identify trends, barriers, and opportunities for improvement.
• Contribute to policy and protocol development for ECM clinical best practices.
• Collaborate with leadership to refine workflows that improve efficiency and impact.

Impact Example:
You notice high ER utilization among unhoused members and help design a proactive outreach plan—reducing avoidable emergency visits and improving stability.

Requirements

Required Qualifications

• Active and unrestricted Registered Nurse (RN) license in California.
• 2+ years of direct clinical experience in settings such as:
• Community health centers
• Acute or post-acute care
• Public health programs
• Behavioral health or SUD treatment programs
• Experience working with Medi-Cal populations, including individuals who are:
• Homeless or at risk of homelessness
• Justice-involved
• Living with SMI/SUD
• Facing multiple chronic health conditions
• 50% Travel / Field Work (Required)

Preferred Qualifications

• Experience with CalAIM ECM, Whole Person Care (WPC), or Health Homes Program.
• Familiarity with managed care workflows and interdisciplinary team collaboration.
• Bilingual proficiency (especially in Spanish, Mandarin, Vietnamese, or Tagalog) is a plus.
• Certification in Case Management (CCM, ACM, or similar) is an asset.

Benefits