Registered Nurse

At ClinNEXUS - we are changing lives through our mission of "Navigating Complexity, Empowering Lives" and growing fast! We're pioneering a transformation in the American healthcare system through proactive community engagement at the grassroots level. Our goal is to forge social connections, enhance clinical outcomes, and lower healthcare expenses for our patients. How we do this is by being proactive via individualized patient assessments, which ensures we are fully equipped to address every patient and their unique needs. To learn more about our innovative solutions and how we're simplifying healthcare, visit our website at You Are: In partnership with health plans and clinical providers, the ClinNEXUS Enhanced Care Management (ECM) Registered Nurse works to build relationships with people experiencing homelessness and/or multiple chronic health conditions. The ECM Registered Nurse will be responsible for review of patient care plans, addressing the patient’s medical and behavioral health needs, with such review focused on identifying appropriate clinical services to be provided to individuals by third-party providers. The ECM Registered Nurse will not be responsible for providing clinical services directly to an individual. In addition, the ECM Registered Nurse provides advocacy, and assists with connection to health services, housing, and other social services. The ECM Registered Nurse employs health coaching techniques to foster patient engagement, patient education, coaching, and access to and care navigation of systems to improve health outcomes. The ECM Registered Nurse will primarily interact with individuals via remote teleconferencing technologies and may also interact in-person. The ECM Registered Nurse demonstrates deep cultural competency, leans into patients’ diverse beliefs, values, and social norms, and ensures care is provided in a culturally and linguistically appropriate manner to meet the needs of all patients served. Responsibilities: Showcase exemplary communication, and organizational prowess to cultivate a vibrant and positive work atmosphere. Assist the Enhanced Care Management (ECM) team regarding members’ physical and medical needs. Participate in the review of and support of member-centered care plans for enrollees. Assist in identifying health care resources that focus on general health conditions, treatments, and interventions specific to each individual's health needs and consistent with standards of care. Monitor individualized care plans and support members to comprehend care plans and instructions, motivating them to actively engage in their health journey. Diligently monitor services to ensure adherence to care plan goals. Actively consult with Care Managers to review medical visit summaries, discharge papers, prepare for upcoming appointments, or review appointment outcomes to help ensure enrollees are being positioned to receive appropriate clinical and social services from third-parties with whom ClinNEXUS works. Assist Care Managers to implement health and preventive care education for acute health conditions, chronic disease management, and medication monitoring techniques. Engage vulnerable populations as part of a multidisciplinary outreach team, including home visits, accompaniment to appointments, outreach to hospitals, homeless shelters and other settings, as needed. Help address Social Determinants of Health and enhance connections to community-based organizations. Work with the ECM team to be aware of and understand hospital admission/ discharge plans with the behavioral health clinician, PCP, pertinent specialists, and other organizations with the goal of preventing readmissions, if possible. Coordinate medication review and reconciliation following transitions in care. Assist the ECM team to implement prevention and engagement activities. Engage in quality improvement efforts for ECM team operations. Assess the needs of patients with the ECM team, identifying social determinants of health and recommending appropriate follow-up and community connections. Coordinate identification of needed member care activities by third parties, through implementation of home visits and offering culturally sensitive support for effective medical care and behavioral change within the team. Assist members in accessing resources, including appointment scheduling and navigating program applications. Foster positive relationships with team members, patients, providers, and community representatives to enhance teamwork and service excellence. Provide exceptional service to all stakeholders, ensuring culturally and appropriate care, attending meetings as necessary, and upholding established policies and procedures. Other duties and projects as assigned. Requirements: Valid Registered Nurse (RN) license in California. CPR certification (American Heart Association or Red Cross). Knowledge of medical terminology and medications. Ability to work independently with minimal supervision. Excellent verbal and written communication (in English), negotiation, and relationship-building skills. Self-driven, motivated and highly empathetic. Resilience to deal with various situations. High level of empathy and ability to engage with people with various backgrounds. A technical aptitude with strong analytical, critical thinking, and reporting abilities. Ability to effectively interact and build collaborative relationships with community agencies, members, and clinical personnel. Valid California driver’s license, reliable personal transportation, proof of insurance, and a driving record in good standing. Proficiency in utilizing electronic health records and related software, as well as computer, technology platforms including documentation systems, data reporting tools, and virtual communication platforms (e.g., Google Workplace Suite, HealthCloud for SalesForce, Smartsheet) to conduct administrative duties, keep track of health records, research, and professional networking. Meet and maintain credentialing requirements with contracted healthcare partners, including background screening, drug testing, FACIS (Fraud and Abuse Control Information System) checks, ID or licensure verification, and ability to produce applicable vaccination or immunization records or declinations, in order to access partner systems or facilities. Working Conditions/Physical Requirements: Ability to work remotely, with reliable internet access. Frequent use of computers, phones, video conference tools and related office equipment. Requires high manual dexterity and prolonged, extensive standing, sitting, walking, and lifting. Adequate hearing and clear speech for in-person or telephone communication. Speak clearly to communicate information to members and staff. Vision suitable for reading various documents, including memos, screens, and forms. Ability to reach above the shoulder level to work. Ability to bend, squat and sit, stand, stoop, crouch, reach, kneel, twist/turn, etc. Regular independent travel for home visits and community-based meetings. Occasionally subjected to irregular hours. May be exposed to infections and contagious diseases. Nice to haves: Bachelor of Science in Nursing. Knowledge of the local community where providing service and residency in the service-area. Experience working in care management. Strong verbal and written ability in English and Spanish, Hmong or Punjabi preferred. Compensation: Hourly Pay Rate: The good faith pay range for this position is $44.00 to $56.00 per hour. The specific pay rate within this range will be based on the candidate's qualifications, including experience, skills and geographic location. #J-18808-Ljbffr