DescriptionPosition OverviewThe Enhanced Care Management (ECM) Registered Nurse (RN) must be passionate about healthcare and want to make a difference in the lives of others while acting as a mission-driven catalyst to help Lumira Healthcare deliver the best quality of care and excellent service to our patients and their families.
The ECM RN provides clinical oversight, nursing care coordination, and care transition support for high-risk, high-utilizing patients enrolled in the ECM program. This role is designed to support program expansion, care coordination capacity, and improved outcomes for ECM participants.
The ECM RN works collaboratively with ECM Case Specialists, primary care providers, behavioral health teams, and community partners to deliver comprehensive, person-centered care in alignment with grant objectives and CalAIM ECM requirements.
Essential Functions, Duties, and ResponsibilitiesClinical Care & Coordination- Conduct comprehensive nursing assessments for ECM participants, including chronic condition management, medication review, risk stratification, and identification of unmet clinical needs.
- Support development, implementation, and ongoing evaluation of individualized person-centered Care Plans in compliance with CalAIM ECM standards.
- Provide clinical consultation and guidance to ECM Case Specialists for medically complex cases
- Identify changes in participant condition, initiate timely interventions, and escalate care appropriately in collaboration with providers.
Care Transitions & Utilization Management- Support transitions of care following hospitalizations, emergency department visits, and skilled nursing facility stays
- Review discharge instructions, perform medication reconciliation, and ensure timely post discharge follow-up appointments.
- Actively contribute to reducing avoidable hospital admissions and emergency department utilization through proactive care coordination.
Interdisciplinary Collaboration- Collaborate with primary care, specialty providers, behavioral health, and social service teams
- Coordinate care with managed care plans, health plans, and community-based organizations to address medical and social needs.
- Participate in interdisciplinary care team meetings, case conferences, and grant-related activities
Patient Education & Advocacy- Provide education to participants and caregivers on disease management, medications, and preventive care and self-management strategies.
- Support patient engagement, adherence to care plans, improved health literacy
- Advocate for participant needs within healthcare and social service systems
Documentation & Compliance- Maintain timely, accurate, and compliant documentation in the electronic health record (EHR) consistent with CalAIM ECM requirements.
- Track and report required grant metrics, outcomes, and performance measures.
- Assist and support internal and external audits, quality improvement initiatives, and program evaluations required by the grant.
Additional Responsibilities- Provide advanced clinical consultation for complex or high-risk ECM cases.
- Support ECM program ongoing development, workflows, optimization, and implementation of best practices.
- Contribute to continuous quality improvement activities aligned with grant deliverables
- Demonstrates competence with the mission, vision, and values of the organization in providing quality services to the community.
- Other work-related duties as assigned. Duties and responsibilities may be added, deleted, or changed at any time at the direction of leadership, formally or informally, either verbally or in writing.
- Maintains confidentiality and respect for all sensitive information.
- Displays a positive, professional, and respectful demeanor at all times towards employees, peers, professional contacts, and patients served, maintaining a professional appearance and positive image for Lumira.
- Contributes as part of the team by promoting positive staff interactions and maintaining open communication with other programs and departments.
- Attends and actively participates in all meetings (e.g., department meetings, program meetings, staff meetings) and other activities as required or assigned.
Education, Knowledge, Skills, and AbilitiesEducation and Experience- Associate's degree in nursing (ADN) required. Bachelor's degree in nursing (BSN) preferred
- Minimum of 2 years of clinical nursing experience. Preference will be given to those with experience in FQHC or experience working with high-risk and underserved populations.
- Experience in care management, case management, population health, or community-based care preferred. Medi-Cal populations and CalAIM/ECM Programs.
Certification/License- Active, unrestricted Registered Nurse (RN) license in the State of California.
- Basic Life Support (BLS) Certification from the AHA.
- Possess a valid driver's license.
Knowledge, Skills, and Abilities- Multi-lingual preferred (English with Spanish, Punjabi, or Portuguese) - speak and read.
- Strong clinical judgment, communication, and documentation skills.
- Ability to work collaboratively within interdisciplinary teams.
- Strong organizational and time-management skills.
- Compassionate, person-centered, trauma-informed approach to patient care.
- Ability to work with high-needs and vulnerable populations.
- High degree of professionalism and reliability.
- Proficiency with EHR systems and clinical documentation.
- Strong knowledge of chronic disease management and care coordination.
- Ability to work independently and follow through on assignments with minimal direction.
- Ability to travel to all clinic sites, hospitals, participant homes, or locations within the community.
