Clinical Lead Care Manager

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 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.

Responsibilities:

• Provides clinical oversight 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.
• Uses 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 enrollees 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 developing new strategies to address clients' needs and enhance care plans.
• Conduct weekly and/or bi-weekly care team meetings with all relevant members of the client's care team, in addition to monthly meetings, to review progress and coordinate care.

Expectations: Prioritize individual and client health and safety, Be able to meet targets and work under pressure. Communicate with tact and professionalism. Ensure confidentiality and effective management of information while maintaining compliance with Federal and State regulations. Display a full understanding of problems with client flow and scheduling to improve the efficiency of program operations, Demonstrate the ability to motivate staff, grasp new skills and procedures, and foster a positive attitude towards change, Model openness, honesty and accountability. Fulfill Illumination Foundation's Guiding Principles of Integrity, Humility, Sustainable Compassion, Quest for Knowledge and Critical Thinking, Client-Centered Care, Innovation, Advocacy, and Stewardship and Compliance, Knowledge and applied practice of HIPAA compliance. Adherence to Illumination Foundation's safety policies and guidelines. Continued sensitivity to and awareness of cultural and linguistic diversity, Ability to prioritize and handle multiple complex tasks

Preferred Experience/Minimum Qualifications: Required: Valid Registered Nurse (RN/LVN) license in California, Experience working with vulnerable populations, including people 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: Bilingual in English and Spanish. At least 2 years of experience working with at risk/unhoused individuals Proficiency in Google Suite (Mail, Docs, Sheets, Calendar).

Benefits:

• Medical Insurance funded up to 91% by Illumination Foundation (Kaiser and Blue Shield), depending on the plan
• Dental and Vision Insurance
• Life, AD&D and LTD Insurance funded 100% by Illumination Foundation
• Employee Assistance Program
• Professional Development Reimbursement
• 401K with Company Matching
• 15 days' vacation PTO/year
• 6 days of sick pay/year
• Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans