RN Case Manager (PHM)- Bakersfield 1.2

RN Case Manager

The RN Case Manager provides advanced case management services across the Population Health Management (PHM) continuum, serving members with needs ranging from low-risk preventive outreach to highly complex medical, behavioral health, and social challenges. The RN collaborates with the interdisciplinary care team to deliver enhanced care coordination, sign off on individualized care plans, monitor clinical and social service interventions, and support member engagement in self-management goals. This position serves as a clinical lead within the PHM program by managing complex cases, conducting nursing assessments, and ensuring compliance with all applicable regulatory, accreditation, and program requirements. The role may also require assignment at a designated clinic site, where the RN will provide case management services in collaboration with members, providers, and care teams.

Job Duties and Responsibilities:

• Manage a caseload of members across the PHM continuum, with emphasis on complex and high-risk cases.
• Conduct comprehensive nursing assessments addressing medical, behavioral, and social needs.
• Develop, approve, and sign off on individualized, person-centered care plans (ICPs) in collaboration with members, caregivers, and the care team.
• Reassess members at appropriate intervals based on risk level, clinical status, or care plan goals.
• Review and sign off on care plans developed in collaboration with LVNs to ensure clinical accuracy and completeness.
• Provide culturally appropriate and accessible communication with members through telephonic, virtual, and in-person outreach. RN Case Managers may also attend critical appointments with members to support care plan execution and address barriers to engagement.
• Assist members with scheduling appointments, providing reminders, arranging transportation, coordinating medication reviews, and following up to ensure referrals and services were completed.
• Provide education, coaching, and motivational interviewing to support lifestyle changes, medication adherence, and chronic disease self-management.
• Ensure closed-loop referrals to community supports, housing, and social service agencies, with follow-up to confirm services were delivered, including care services authorized by the organization. Address escalated clinical issues impacting service delivery as appropriate.
• Provide transitional care services, including discharge risk assessments, post-discharge follow-up, medication reconciliation, contingency planning, and coordination of post discharge services (home health, DME, transportation, prescriptions, follow-up visits).
• Coordinate with providers to ensure safe and effective care transitions between inpatient, emergency, and outpatient settings.
• Assess member needs, identify changes in condition or red-flag symptoms, and escalate concerns to the treating provider or Medical Director as appropriate.
• Organize, present, and actively participate in Interdisciplinary Care Team (ICT) meetings to review care plans, monitor progress, and update goals.
• Monitor member conditions, health status, medications, and care planning on an ongoing basis, escalating as needed.
• Monitor quality metrics and contribute to achieving organizational performance goals.
• Document all case management activities accurately and timely in the electronic health record (EHR).
• Provide input into process improvement initiatives and serve as a clinical resource to team members.
• Participate in daily huddles, departmental meetings, ICTs, and staff training.
• Support orientation and mentoring of new case management staff as assigned.
• Perform other duties as assigned.

Qualifications:

• Current, unrestricted Registered Nurse (RN) license in the State of California.
• Bachelor of Science in Nursing (BSN) preferred.
• Valid driver's license and reliable transportation for community-based and clinic assignments.
• Minimum of 2 years of nursing experience. Case management, care coordination, or population health experience preferred.
• Experience managing complex cases across medical, behavioral health, and social domains.
• Prior experience with Medi-Cal, Medicare, and/or D-SNP populations strongly preferred.

Skills and Abilities:

• Demonstrated knowledge of nursing processes, case management, and continuity of care.
• Ability to work with members to influence behavior through care goal negotiation and support of self-management.
• Sensitivity to members' social, cultural, language, physical, and financial differences.
• Ability to respect and support the needs of members, caregivers, and team members while providing excellent customer service.
• Strong problem-solving skills, with the ability to identify issues and propose effective solutions.
• Ability to prioritize and adapt to changes in member situations and needs.
• Strong organizational skills, with the ability to work independently while managing multiple tasks throughout the day.
• Excellent verbal and written communication skills, including the ability to explain complex health and benefit information in a clear manner.
• Proficiency in the use of electronic case management systems and Microsoft Office (Word, Excel, PowerPoint), databases, and internet-based tools.
• High attention to detail with accuracy, thoroughness, and persistence in documentation and follow-up.
• Ability to work effectively both independently and as part of an interdisciplinary team, while adapting to changing environments.
• Commitment to professionalism, continuous learning, and quality improvement.
• Ability to always maintain confidentiality and professionalism.

Universal Healthcare MSO, LLC