ECM Registered Nurse at Gracelight Community Health in Los Angeles, CA

The Enhanced Care Management (ECM) Registered Nurse (RN) provides clinical expertise and care management support to individuals with complex medical, behavioral health, and social needs. As a key member of the interdisciplinary ECM team, the RN conducts comprehensive health assessments, develops and monitors individualized care plans, supports care transitions, provides disease management education, and assists members in navigating healthcare and community-based systems.

The ECM RN serves as a clinical resource for ECM staff and collaborates with providers, hospitals, health plans, and community partners to improve health outcomes and reduce barriers to care. This position supports whole-person care by addressing the medical, behavioral, and social factors that impact member health and well-being.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

1. Conducts comprehensive nursing assessments for ECM members with complex health conditions and high-risk care needs.
2. Identifies clinical, behavioral health, functional, and social determinants of health needs impacting member outcomes.
3. Participates in development and implementation of individualized care plans in collaboration with members and interdisciplinary team members.
4. Provides clinical consultation and guidance to ECM Care Managers and other ECM staff.
5. Supports management of chronic diseases through member education, coaching, and evidence-based interventions.
6. Performs medication reconciliation and identifies medication-related barriers, risks, and adherence concerns.
7. Reviews hospital, emergency department, specialist, and primary care records to support care coordination activities.
8. Coordinates transitions of care following hospitalization, emergency department visits, skilled nursing facility stays, and other care settings.
9. Monitors member progress toward care plan goals and recommends adjustments when appropriate.
10. Identifies changes in health status and facilitates timely referrals to appropriate providers and services.
11. Collaborates with primary care providers, specialists, behavioral health providers, hospitals, health plans, and community-based organizations to ensure coordinated care delivery.
12. Participates in interdisciplinary case conferences and case reviews for high-risk members.
13. Provides health education related to disease processes, medication management, preventive care, and self-management strategies.
14. Assists members in understanding treatment plans and navigating complex healthcare systems.
15. Conducts outreach and engagement activities to establish and maintain therapeutic relationships with ECM members.
16. Meets members in community settings, homes, shelters, healthcare facilities, and other approved locations as appropriate.
17. Supports ECM program compliance with DHCS, Cal AIM, health plan, and regulatory requirements.
18. Ensures timely completion and maintenance of assessments, care plans, progress notes, and required documentation.
19. Maintains confidentiality and compliance with HIPAA and organizational policies.
20. Participates in quality improvement initiatives, audits, reporting activities, and program development efforts.
21. Maintains current knowledge of ECM, Cal AIM, population health, and care management best practices.
22. Performs other duties as assigned.

Qualifications

• Current and unrestricted Registered Nurse (RN) license in California.
• Bachelor's degree in nursing (BSN) preferred.
• Experience in care management, case management, or population health preferred.
• Experience working with high-risk, high-utilizing, or medically complex populations preferred.
• Knowledge of chronic disease management, care coordination, and social determinants of health.
• Familiarity with CalAIM, Enhanced Care Management, Community Supports, Medi-Cal managed care, and value-based care models preferred.
• Strong clinical assessment and critical thinking skills.
• Ability to work effectively in a team-based care environment.
• Valid driver’s license and reliable transportation.
• Current CPR certification required.
• Bilingual (Spanish, preferred).
• Regular on-site presence required.

Salary Range

$43.47 - $54.40 Hourly