RN Clinical Lead Care Manager
Illumination FoundationAbout the role
Homelessness is the largest social and public health crisis in California. Illumination Health + Home 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 ECM Clinical Lead Care Manager is responsible for collaboration with the ECM team to serve homeless
individuals with serious mental illness, substance use disorders and/or complex medical issues. The ECM
RN/LVN will assist in addressing the social determinants of ECM smart goals. The ECM will collaborate
closely with a multi-disciplinary care team to specifically include providing clinical support to Care
Coordinators, Lead Care Managers and the entire ECM team of employees. They will measure progress
towards the goals outlined in client care plans or assessments. The ECM will collaborate with a broader
care team (PCP, BH clinicians etc.,) to ensure ECM enrollees are receiving the services outlined in the care
plan.
This is role requiring adherence to and application of evidence-based practices, knowledge of client and
service barriers as well as social determinates of health, and providence of appropriate coordination of
services to populations of focus. They help navigate health care services and systems, promote health and
preventative care, and work closely with the client’s Care Team.
The pay offered for this role is $78,000 - 84,000 Annually.
The schedule for this role is Monday - Friday, 8:30am to 5:00pm.
New graduates encouraged to apply!
Responsibilities
Provides clinical oversite to support Lead Care Managers/Care Coordinators. This includes
chronic disease management and medication monitoring.
● Engages vulnerable populations as part of a multidisciplinary outreach team. This includes
home visits, outreach to hospitals, homeless shelters and other settings, as needed.
● Provides clinical oversight and tracking of care plans.
● Participates in the review of developed patient-centered care plans and reviews any
updated care plans of all enrolled members.
● Works with hospitals to coordinate discharge plans with the behavioral health clinician,
PCP, ACO, MCO etc.
● Performs timely medication reconciliation following transitions in care. Supports medication
adherence.
● Use data to evaluate outcomes from targeted interventions of clients. Assists in developing
appropriate adjustments to care plans based on this data.
● Implements prevention & engagement activities. By presenting case conferences at scheduled
monthly/weekly meetings.
● Provides health coaching for groups of enrollees or individual enrollers as needed.
● Engages in quality improvement efforts. By participating in audits by various program administrators.
● ECM RN/LVN shall attend appropriate disciplined training, webinars, meetings and conferences.
● Promote monthly Health Promotion topics/materials.
● Complete care plans and utilize Electronic Health Record(s) (EHR) and client databases (i.e., MIS,
Champ, or Health plan programs if applicable) to track and maintain accurate case notes, client,
and program data in SMART Format where applicable.
● Engage with the Client care Team by participating in weekly Interdisciplinary Care Team meetings to
evaluate program effectiveness and client progress, while
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