Care Team Manager (Licensed RN, LMFT, or LCSW)

About Us Heritage Health Network (HHN) was born from a vision to bridge the gap in healthcare accessibility, intuitiveness, and responsiveness. Our story is deeply intertwined with the dedication of our founder, a seasoned prosthetist orthotist with over 15 years of experience serving our community. Committed to improving health outcomes, our founder's expertise and deep community ties have been instrumental in shaping HHN's approach and services. The genesis of HHN was fueled by the need to address the unique challenges faced by Black Americans and individuals with limb loss. Our logo, featuring a bridge, symbolizes our commitment to connecting these communities with comprehensive, empathetic healthcare solutions. It represents our role as a crucial link between medical care and the social determinants of health that are vital for holistic well-being. With a foundation in Enhanced Care Management (ECM), HHN has evolved into a holistic, person-centered network. We believe in treating the individual, not just the condition, by considering the full spectrum of their life's context. This approach stems from our founder's deep understanding of the intricacies of patient care, honed through years of hands-on experience. Today, HHN stands as a vibrant embodiment of community-centric healthcare, continually adapting to meet the changing needs of those we serve. Our journey, marked by resilience, innovation, and unwavering dedication, is a testament to our founder's vision of a healthier, more empowered community. We are proud to continue this legacy, forging new paths towards improved health outcomes and a brighter future for all. Job Description This is a remote position. We are seeking a Registered Nurse Care Manager (RNCM) to provide clinical oversight for a team of non clinical Lead Care Managers. In this fully remote role, you will review member charts in the electronic medical record (EMR) system, assess care plans, and collaborate with Lead Care Managers to ensure members receive comprehensive, high-quality clinical care. Most hours can be completed at your convenience. However, one hour per week will be required to participate in case reviews with the ECM team. Requirements Key Responsibilities Clinical Oversight & Quality Assurance Review member charts in the EMR system to assess care plans, medical history, and treatment adherence. Ensure the quality and appropriateness of care coordination for members in the ECM program. Provide clinical guidance to non-clinical Lead Care Managers, helping them navigate complex cases. Identify gaps in care and recommend interventions to improve health outcomes. Care Coordination & Collaboration Work closely with a multidisciplinary team that includes: Lead Care Managers Behavioral Health Care Managers Community Health Workers Partner with healthcare providers and community organizations to facilitate referrals and-access to care. Participate in weekly team case reviews to discuss high-risk members and ensure best practices in care management. Support care transitions by coordinating with hospitals and providers to optimize discharge planning. Regulatory Compliance & Documentation Ensure compliance with Medi-Cal ECM guidelines and other healthcare regulations. Maintain accurate documentation in the electronic health record (EHR) system. Provide clinical input for monthly reports required by health plans and regulatory bodies. Qualifications License: Active Registered Nurse (RN) license in California. Experience: Minimum 2 years of nursing experience, with at least 1 year in care management, case management, or leadership. Experience working with vulnerable populations and individuals with complex medical and social needs. Familiarity with Enhanced Care Management (ECM) or similar care coordination programs are preferred. Skills & Knowledge: Strong clinical assessment and care planning skills. Knowledge of Medi-Cal, Medicare, and care management best practices. Excellent communication and teamwork abilities. Proficiency in electronic medical records (EMR) systems.