Enhanced Care Management - Registered Nurse

Position Overview The Enhanced Care Management (ECM) Registered Nurse (RN) must be passionate about healthcare and want to make a difference in the lives of others while acting as a mission-driven catalyst to help Lumira Healthcare deliver the best quality of care and excellent service to our patients and their families.

The ECM RN provides clinical oversight, nursing care coordination, and care transition support for high-risk, high-utilizing patients enrolled in the ECM program.

This role is designed to support program expansion, care coordination capacity, and improved outcomes for ECM participants.

The ECM RN works collaboratively with ECM Case Specialists, primary care providers, behavioral health teams, and community partners to deliver comprehensive, person-centered care in alignment with grant objectives and CalAIM ECM requirements.

Essential Functions, Duties, and Responsibilities Clinical Care & Coordination Conduct comprehensive nursing assessments for ECM participants, including chronic condition management, medication review, risk stratification, and identification of unmet clinical needs.

Support development, implementation, and ongoing evaluation of individualized person-centered Care Plans in compliance with CalAIM ECM standards.

Provide clinical consultation and guidance to ECM Case Specialists for medically complex cases Identify changes in participant condition, initiate timely interventions, and escalate care appropriately in collaboration with providers.

Care Transitions & Utilization Management Support transitions of care following hospitalizations, emergency department visits, and skilled nursing facility stays Review discharge instructions, perform medication reconciliation, and ensure timely post discharge follow-up appointments.

Actively contribute to reducing avoidable hospital admissions and emergency department utilization through proactive care coordination.

Interdisciplinary Collaboration Collaborate with primary care, specialty providers, behavioral health, and social service teams Coordinate care with managed care plans, health plans, and community-based organizations to address medical and social needs.

Participate in interdisciplinary care team meetings, case conferences, and grant-related activities Patient Education & Advocacy Provide education to participants and caregivers on disease management, medications, and preventive care and self-management strategies.

Support patient engagement, adherence to care plans, improved health literacy Advocate for participant needs within healthcare and social service systems Documentation & Compliance Maintain timely, accurate, and compliant documentation in the electronic health record (EHR) consistent with CalAIM ECM requirements.

Track and report required grant metrics, outcomes, and performance measures.

Assist and support internal and external audits, quality improvement initiatives, and program evaluations required by the grant.

Additional Responsibilities Provide...