CalAIM Nurse Case Manager

About the Organization Stepping Up Santa Cruz is a non‑profit organization dedicated to supporting individuals with complex needs, including mental health, substance use, developmental disabilities, medical vulnerability, and homelessness. We go beyond providing services; we empower individuals to reach their full potential by offering high‑quality, individualized advocacy. We firmly believe in tailoring our support to each person’s unique needs and circumstances. Our passionate team builds rapport to connect individuals with essential resources they self‑identify, ensuring they have everything they need to thrive. We believe staff loyalty is earned by giving them the tools to be successful and fulfilled and by rewarding hard work through great pay and benefits. About the Position You’ll play a vital role as the Enhanced Care Management (ECM) Nurse, part of our integrated service delivery model that takes a whole‑person, team‑based approach to serving members. Nurse Case Managers work with a team providing comprehensive care coordination and support to members enrolled in CalAIM’s ECM (Enhanced Care Management) and CS (Community Supports) programs. This dynamic role demands initiative, integrity, dedication, and a genuine desire to make a positive impact on people’s lives. Prepare to work in a diverse environment, combining the satisfaction of fostering the growth of your team with community outreach and direct engagement with members. Responsibilities Manage a small caseload to ensure understanding of processes and identify areas for improvement. Help members with complex needs get assistance by coordinating and managing their care. Pull outside medical records, including CCAH and SCHIO (the local health information exchange), and provide updates to the medical care team / PCP. Act as the primary point of contact for other medical specialists involved in the member’s care. Attend specialist and medical appointments with members as needed to support attendance and understanding. Utilize screening tools and evidence‑based practices to support member‑centered care and mutual goal development. Conduct in‑depth needs assessments and develop personalized care plans in collaboration with members, ensuring strengths‑based alignment with Trauma‑Informed Care (TIC) principles and Harm Reduction philosophy. Provide risk assessment and crisis intervention services as needed. Coordinate care with providers (doctors, therapists, social workers) through in‑person consultations and remote communication, prioritizing culturally competent and member‑centered approaches and developing shared treatment plans, goals and interventions. For members currently hospitalized, in skilled nursing, or receiving other inpatient care, collaborate with provider staff on discharge planning and advocate for in‑home services (visiting nurses, physical and occupational therapy, IHSS, etc.). Consult and coordinate with community systems to facilitate linkage, manage referrals and advocate for member needs, focusing on supporting identified treatment goals. Conduct member meetings at their home or place of choice to build rapport, assess living environment and provide direct support to ensure safety and stability. Advocate for member needs, ensuring they receive appropriate, individualized, and trauma‑informed care regardless of location or service. Monitor member progress and adapt care plans as needed based on member interactions, feedback, and observations, aligning with best practices for case management and eligibility for billing. Document all member interactions and services accurately and daily, ensuring case notes, plans and assessments meet required standards for billing and quality delivery. Use rapport, respect and clear expectations to de‑escalate potentially volatile situations, employing effective communication techniques and understanding the impact of trauma and past experiences. Support the entire ECM/CS team with the varied complex medical needs of members. Receive, assess and incorporate feedback to grow personally and professionally. Assist in the development and planning of processes for the four goals of taking care of members, taking care of staff, financial sustainability, and high integrity/professional service delivery. Contribute to a positive and collaborative team environment, both in the office and during outreach activities, fostering inclusivity and respect for diverse experiences. Attend mandatory trainings on‑site, online, and off‑site at partner agencies for professional development to provide the highest level of service. Other duties as assigned. Minimum Qualifications LVN from an accredited school (RN preferred). Experience in case management. Valid California Driver’s License and ability to operate both personal and company vehicles. Eligible to work in the US. Must be 18 years of age or older. Minimum two years of experience working with individuals with complex needs. Reliable transportation and ability to travel within a 50‑mile radius for meetings, trainings and member appointments (mileage reimbursement is provided for use of your own vehicle). Skills & Abilities Excellent communication, interpersonal and problem‑solving skills. Ability to complete all documentation in accordance with organizational and Medi‑Cal requirements. Strong computer literacy in Microsoft Office and Excel and Electronic Health Records (EHR) and willingness to learn other relevant software. Experience working in a CalAIM ECM/CS program desired. Demonstrated understanding and application of Trauma‑Informed Care (TIC) principles and Harm Reduction philosophy. Strong soft skills, including assessment, planning and intervention. Ability to work independently and collaboratively in both office and community settings. Strong organizational and time‑management skills to prioritize competing responsibilities and adapt to dynamic situations. Strong work ethic, self‑motivation and a genuine desire to help others. Must pass a relevant background check as a Medi‑Cal provider upon provisional offer of employment and maintain eligibility. Ability to lift up to 35 lbs occasionally. Bilingual (Spanish/English and Mixteco preferred) is a plus with hourly bonus of $1.00 per hour. Ability to drive a van and trailer is a plus. Compensation and Benefits Hourly rate of $48.08 per hour with potential for performance‑based pay increase after 6 months. Full time 32‑hour work week to support a healthy work‑life balance. Generous Paid Time Off (PTO) and sick leave of 4 weeks per year for relaxation and recharge. Employees accrue 1 hour of PTO for every 10.4 hours worked, potentially 160 PTO hours per year (approximately 20 days off for a 32‑hour week). Comprehensive benefits package, including no‑cost health coverage with optional dental and vision coverage. Company‑sponsored 403(b) retirement savings plan with a generous employer match of 100% of contributions up to 5% of salary. Extensive training, coaching and tools to empower you to create positive change in members’ lives and support your professional growth. Opportunities for advancement. Pay bonus of $1.00 per hour for bilingual English/Spanish or Mixteco. Potential for pay bonuses for relevant certifications. Additional Information CalAIM is a new program, offering an exciting opportunity to be at the forefront of impactful work. This challenging yet rewarding position allows you to directly impact members’ lives through a dynamic mix of office work and community outreach. If you are a passionate, driven individual with a Nursing degree, a willingness to go the extra mile, a heart for helping others, and an acknowledgment of your own self‑care, this may be your dream job. We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, creed, ancestry, color, sex (including pregnancy, sexual orientation or gender identity), national origin, age, weight, height or other physical characteristics, marital status, veteran status, disability status, genetic information, or any other protected characteristics. #J-18808-Ljbffr