Job Description

The RNCM- bilig partners closely with Clinical Operations, Care Team Operations, Lead Care Managers, Community Health Workers, Behavioral Health providers, Compliance, and external medical and social service partners. Collaboration occurs daily to support assessments, care planning, escalations, transitions of care, and member outcomes.

Responsibilities

• Conduct comprehensive clinical assessments (including medical history, risk factors, and medication review) and develop person-centered care plans with SMART goals based on medical, behavioral, and social needs.
• Provide medication reconciliation, health education, and condition-specific teaching to strengthen member understanding, self-management, and adherence.
• Collaborate with Lead Care Managers, CHWs, Behavioral Health, Housing Navigation, providers, and community partners to coordinate services and resolve medical and social barriers.
• Triage clinical concerns, identify red flags, and escalate appropriately to NP/MD partners; provide brief interventions within RN scope as needed.
• Participate in interdisciplinary Systematic Case Reviews (SCR), IDT meetings, and case conferences, offering clinical recommendations and follow-up planning.
• Coordinate transitions of care (TOC) by supporting post-hospital follow-ups, reconciling medications, scheduling timely appointments, and ensuring continuity.
• Maintain accurate, timely, audit-ready documentation in ECW, Google Suite, and payer/health plan portals; ensure all clinical assessments, screenings, and care plans meet required timelines.
• Engage members through relationship-based and trauma-informed approaches, building trust with individuals who may struggle with traditional healthcare systems.
• Identify gaps in care, clinical risk, or environmental barriers and collaborate with care teams to implement timely interventions.
• Support HHN’s startup model by adapting to evolving workflows, contributing to clinical process improvements, and helping build scalable care coordination practices.

Skills Required

• Strong clinical assessment, triage, and critical-thinking skills, bilingual speaking, writing.
• Expertise in care planning, chronic disease management, and clinical documentation.
• Proficiency with eClinicalWorks (ECW), Google Suite, RingCentral, and payer/health plan portals.
• Ability to interpret labs, vitals, diagnostics, and clinical red flags to guide care decisions.
• Strong medication knowledge and ability to perform accurate medication reconciliation and provide member education.
• Experience supporting members with complex medical, behavioral health, and social needs.
• Ability to work independently while effectively partnering with a multidisciplinary team.
• Excellent written and verbal communication skills with demonstrated cultural humility and trauma-informed communication.
• Strong organizational and time-management skills; able to manage multiple high-acuity cases simultaneously.
• Comfort working in a fast-paced, evolving startup environment with shifting workflows and new processes.
• Reliable HIPAA-compliant remote workspace with stable internet connection.

Competencies

• Clinical Judgment: Applies strong nursing assessment and evidence-based decision-making.
• Collaboration: Works effectively across interdisciplinary teams and external partners.
• Problem Solving: Identifies issues early and develops practical solutions quickly.
• Communication: Delivers clear education, instruction, and support to diverse populations.
• Adaptability: Thrives in ambiguity, adjusts quickly to changes, and supports startup operations.
• Cultural Competence: Engages respectfully with diverse and vulnerable populations.
• Quality Focus: Maintains high standards for documentation, timeliness, and compliance.
• Member-Centered Care: Approaches each member with empathy, respect, and a commitment to holistic care.

Job Requirements

• Education:
• Associate or Bachelor’s degree in Nursing required; BSN strongly preferred.
• Licensure:
• Active, unrestricted Registered Nurse (RN) license in the state of California.
• Experience:
• Minimum 3 years of nursing experience.
• Bilingual - Spanish
• At least 1 year in care management, case management, or complex care coordination.
• Experience with chronic disease management, behavioral health integration, or ECM preferred.
• Experience managing members with high medical, behavioral, or social complexity.
• Familiarity with Medi-Cal populations, health plans, and care management best practices.

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