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.
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.
Job Description The ECM Clinical Lead Care Manager 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.
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 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 Microsoft Office (Outlook, Word, Excel, Teams)
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
10 days' vacation PTO/year
6 days of sick pay/year
Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans