RN Case Manager (Remote)
hace 24 días
San Jose
Job Description Empowering Wellness, Transforming Lives Optima Medical Management Group is dedicated to enhancing the quality of life by promoting wellness. At Optima MMG and all of its divisions: Serene Health, Community Support, and American TrueCare, our mission is to provide comprehensive support and care that not only addresses immediate concerns but also fosters long-term well-being. As pioneers in the field, we aspire to lead in member care outcomes and set new standards for excellence and innovation. We are committed to empowering our members to achieve self-sufficiency in health, creating a ripple effect that strengthens families and communities. Our work culture at Optima MMG is built on pride, passion, and a collective commitment to making a positive difference in people's lives. Our team members are dedicated problem-solvers who bring their unique skills and perspectives to the table. We believe that by fostering a collaborative and supportive environment, we can unlock the full potential of our team and, in turn, provide the best possible care to our members. A career at Optima MMG is an opportunity to be part of a dynamic and forward-thinking organization. We encourage continuous learning and professional growth, providing our employees with access to industry experts, cutting-edge technologies, and a supportive community that values each individual's contributions. Join us on this journey to not only advance your career but to be a driving force in transforming lives and communities through passionate and fulfilling work! Job Summary The RN Clinical Care Manager (CCM) is the clinical anchor of a dedicated care pod within the Enhanced Care Management (ECM) program, holding full documentation and clinical oversight responsibility for a cohort of approximately 500 ECM members. Working as an integral, fully remote member of the pod's interdisciplinary Care Team, alongside Lead Care Managers, MAs, and Community Health Workers, the RN CCM ensures that every member's care plan, assessment, and clinical record reflects sound nursing judgment and meets payer and regulatory standards. This role combines the relational, member-engagement strengths of the Lead Care Manager with the clinical expertise, documentation rigor, and oversight responsibilities of an RN Case Manager. Under the general supervision of Enhanced Care Management Leadership, the RN Clinical Care Manager provides clinical oversight and documentation review for all care plans, assessments, and clinical notes generated within the pod, working remotely alongside the Lead Care Managers and Community Health Workers, a who conduct direct member engagement. Through collaboration with Primary Care Providers (PCPs), interdisciplinary Care Team members, and community partners, the CCM ensures that members receive the right care, at the right time, in the right place—supporting improved outcomes and health equity for diverse Medi-Cal populations across the assigned 500-member cohort. Key Responsibilities Pod Nursing, Documentation, and Clinical Oversight • Serve as the RN of record for a cohort of approximately 500 ECM members, holding full responsibility for the accuracy, completeness, and clinical soundness of all documentation within the pod., • Function as an integral, fully remote member of the pod Care Team, partnering closely with Lead Care Managers, MAs, and Community Health Workers who conduct direct member engagement., • Review and provide clinical oversight of care plans, assessments, and progress notes entered by pod team members, ensuring clinical accuracy and appropriateness of the plan of care., • Respond promptly and professionally to clinical escalations from the pod team, ensuring documentation and service delivery adhere to legal and payer guidelines. Care Coordination and Clinical Oversight • Provide clinical sign-off on individualized, whole-person care plans based on comprehensive assessments addressing physical health, behavioral health, substance use, long-term care, housing, and social service needs across the assigned cohort., • Work collaboratively across the healthcare continuum—primary care, specialists, hospitals, behavioral health, and community agencies—to integrate medical and social support., • Monitor member progress and outcomes across the pod's cohort, adjust care plans as needed, and ensure regular follow-up through remote documentation review and telehealth workflows., • Facilitate and identify candidates for safe and effective care transitions, including discharge planning, follow-up appointments, and home-based care coordination., • Advocate for timely access to appropriate treatments, medications, and support services. Clinical Leadership and Quality Improvement • Review utilization patterns of high-risk patients and work with healthcare teams to design interventions that reduce avoidable hospital and ED visits., • Analyze payer and quality performance reports to identify care gaps and implement improvement strategies., • Participate in developing and training team members on quality improvement, safety, and case management best practices., • Maintain compliance with Medi-Cal, HEDIS, and quality standards while advancing health equity across all populations. Population Management Hold clinical oversight for the pod's cohort of approximately 500 ECM members across ECM's populations of focus, including but not limited to: • Individuals experiencing homelessness, • Those with serious mental illness and/or substance use disorders, • Individuals transitioning from incarceration, • High utilizers of emergency services, • Adults at risk of institutionalization or transitioning from nursing facilities, • Pregnant/postpartum individuals facing racial or ethnic birth inequities, • Children and youth in child welfare or California Children's Services (CCS), • Performa additional duties as requiredQualifications Required, • Active California RN license in good standing (required, regardless of the RN's physical location)., • Minimum 2 years of experience as a Registered Nurse; case management or Enhanced Care Management (ECM) experience preferred., • Strong understanding of Medi-Cal, care coordination, and social determinants of health., • Excellent analytical, clinical judgment, interpersonal, and communication skills., • Proficiency in MS Office (Excel, Word, Outlook) and electronic health record systems., • Ability to consistently work required hours of 8:30 a.m.–5:00 p.m. PST, regardless of the RN's home time zone., • Reliable high-speed internet and a private, HIPAA-compliant home workspace suitable for a fully remote clinical role., • Compassionate, nonjudgmental, and culturally sensitive approach.Preferred, • Bachelor's or Associate degree in Nursing, RN license., • Bilingual, Spanish., • Certified Case Manager (CCM) or equivalent certification., • Experience in Managed Care, Community Health, or Behavioral Health settings., • Certification or experience using Motivational Interviewing or empathy-based communication strategies., • Familiarity with regional health disparities and principles of self-management support for chronic conditions.Physical and Work Requirements, • Prolonged periods sitting at a home workstation performing documentation review and computer-based work., • Frequent computer usage; must be able to lift up to 10 pounds., • Occasional evening or weekend work within a 40-hour week. This position provides a unique opportunity to combine clinical expertise with remote, pod-based nursing leadership—empowering members to achieve their health goals through trusted clinical oversight, sound documentation, and coordinated, person-centered care. Pay range $90,000—$110,000 USD Benefits Our full-time employees are eligible for the following benefits enrollment after 60 days of employment: Medical, Dental, & Vision Benefits: We have various insurance options for you and your family. Short & Long-Term Disability Benefits: Protection when you need it most. Voluntary Accident, Voluntary Critical Illness, and Voluntary Hospital Indemnity Plans: Added security for you and your loved ones. Flexible Spending Accounts: Manage your finances with flexibility. Employee Assistance Program (EAP): Support when life throws challenges your way. 401(K): Building your financial future with us. Effective after 1 year of employment. Paid Vacation and Sick Leave: Flexibility for the planned and unplanned. Paid Holidays: Quality time to enjoy celebrations. Employee Referral Program: Share the opportunities and reap the rewards. Company Discount Program: Enjoy savings on everyday expenses and memberships. Equal Employment Opportunity Optima Medical Management Group and its divisions are an Equal Opportunity Employer. Optima MMG is committed to providing employment opportunities for all qualified candidates without discrimination on the basis of race, religion, sex, sexual orientation, gender identity, age, national origin, citizenship, disability, marital status, veteran status, or any other characteristic protected by federal, state or local laws. Optima MMG is committed to providing reasonable accommodation for individuals with disabilities. Pre-Employment Optima Medical Management Group is a drug-free workplace. Employment is contingent upon a successful pre-employment drug screening and background check.
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