Founding Lead RN Case Manager

We’re looking to find our founding Lead RN Case Manager for our MediCal programs in Santa Clara County. As our first Lead RN Case Manager, you will play an essential role in helping us transform end-of-care for our Partners’s patients and their loved ones. The Lead RN Care Manager will provide high quality case management to eligible patients with complex medical and social needs. This individual will perform outreach and engagement activities, conduct a comprehensive assessments, develop care plan, and provide appropriate information and support regarding referrals and be the main support for patients Location: San Jose, California / Santa Clara County Job Type: Full Time Job Responsibilities Assess patient needs in the areas of physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral and linkage to community-based services and supports Oversees the development of the patient care plans and supports SMART goal setting Offer services where the patient resides, seeks care, or finds most easily accessible, including field-based services, office-based, or telehealth Connect patient to other social services and supports that are needed Identify and escalate clinical concerns Advocate on behalf of the patient with health care professionals (e.g. PCP, etc.) Utilize evidence-based practices, such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles Conduct outreach and engagement activities in order to facilitate linkage to the ECM program and log activity in the Care Navigation platform Complete all documentation, including outcome measures within the timeframes established by the individual care plans Maintain up-to-date patient health records in the Electronic Medical Record (EMR) system and other business systems Establishes and maintains effective working relationships with provider offices, County departments and other community agencies, and internal stakeholders related to care coordination for members, disease management, and health education Provide mentorship and coaching to other members of the team Skills and Toolset You’ll Need to Bring Willing and able to work Monday-Friday 8:30am-5:00pm, both in the field and remotely. Current California RN license 2+ years experience as a care manager or case manager Working knowledge of government and community resources related to social determinants of health Excellent oral and written communication skills Positive interpersonal skills required Clean driving record, valid driver's license, and reliable transportation Must have general computer skills and a working knowledge of EMR / Care Management platforms