RN Case Manager

Job Summary: 

The RN Clinical Case Manager provides clinical assessment, care plan development, and ongoing clinical oversight within the Enhanced Care Management (ECM) program. 

This is a non-bedside, RN-led role. The RN Clinical Case Manager serves as the clinical authority for ECM care planning, ensuring medical appropriateness, risk identification, and regulatory compliance. The RN works in close collaboration with ECM Lead Care Managers, who are responsible for care coordination, member engagement, and non-clinical assessments. 

Core Responsibilities: 

• Conduct clinical assessments based on medical history, diagnoses, utilization patterns, medications, and risk indicators. 

• Develop, review, and clinically approve individualized ECM care plans. 

• Identify and monitor clinical and utilization risks impacting member outcomes. 

• Provide RN clinical oversight and guidance to ECM Lead Care Managers executing care plans. 

• Review medication lists for safety concerns, adherence issues, and escalation needs. 

• Collaborate with primary care providers, behavioral health clinicians, and internal care teams. 

• Support transitions of care following emergency department visits, hospitalizations, or other significant events. 

• Ensure care plans are updated based on changes in clinical status or utilization patterns. 

• Ensure care plans and clinical documentation meet Medi-Cal, CalAIM, and ECM program requirements. 

• Participate in audits, chart reviews, and quality improvement initiatives. 

• Provide clinical education and consultation to ECM staff as needed. 

• Contribute to the development and refinement of clinical workflows, tools, and best practices. 

• Maintain timely, accurate, and compliant clinical documentation. 

• Prepare clinical summaries, care plan updates, and progress notes. 

• Support internal reporting related to member outcomes, utilization, and care plan progress. 

• Performs other duties as assigned.  

Required Qualifications:  

• Active California & GA RN license. 

• Associate Degree in Nursing (ADN) required; BSN preferred. 

• Minimum 3 years of clinical nursing experience. 

• Experience working with Medi-Cal and/or managed care populations. 

• Strong clinical judgment and communication skills. 

• Ability to work independently and collaboratively. 

Preferred Qualifications 

• Bilingual English/Spanish 

• Case management or utilization management experience. 

• Familiarity with Enhanced Care Management (ECM) or Health Home programs. 

• Experience supporting audits or regulatory reviews. 

• Training in Motivational Interviewing or trauma-informed care. 

Physical Requirements:  

• Prolonged periods of computer-based work. 

• Ability to lift 10 pounds. 

• Flexibility to support program operations.