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Registered Nurse (RN) Care Manager

Titanium is a healthcare company that puts heart and compassion above all else. Millions of Americans just aren't getting the medical care they need. We're on a mission to change that. For patients that means exceptional support and better care. For providers it means better support and time to focus on patients, and for partners that means higher quality and lower cost.

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The Registered Nurse (RN) Care Manager is an essential member of Titanium Healthcare's Enhanced Care Management (ECM) interdisciplinary team. Enhanced Care Management (ECM) is a Medi-Cal benefit under California Advancing and Innovating Medi-Cal (CalAIM) that provides comprehensive, person-centered care coordination for individuals with complex medical, behavioral health, and social needs.

The RN Care Manager provides comprehensive nursing care management, clinical assessment, medication reconciliation, health education, care coordination, and clinical consultation for members with complex health conditions. Working collaboratively with Behavioral Health Care Managers, Community Health Workers, Care Coordinators, Primary Care Providers, specialists, hospitals, and community partners, the RN Care Manager ensures members receive coordinated, evidence-based care that improves health outcomes and supports successful management of chronic conditions.

The RN Care Manager serves as the clinical resource for the interdisciplinary care team by providing nursing expertise, supporting evidence-based interventions, facilitating transitions of care, and ensuring compliance with Department of Health Care Services (DHCS), Managed Care Plan (MCP), and Titanium Healthcare standards.

This position is hybrid and is based in Victorville, California. Team members are expected to work both remotely and, in the community, conducting face-to-face member visits, attending provider meetings, and participating in team meetings as needed. Local travel throughout the assigned service area is required to provide in-person Enhanced Care Management (ECM) services and support member needs. Standard business hours are Monday through Friday from 8:00 am to 5:00 pm.

Clinical Care Management

• Manage a caseload of ECM members with complex medical needs, primarily Tier 1 and Tier 2 members, using a person-centered approach
• Conduct telephonic and face-to-face member visits based on member acuity, risk level, and Managed Care Plan requirements
• Perform comprehensive nursing assessments to identify clinical needs, barriers to care, and opportunities to improve health outcomes
• Engage members using motivational interviewing and evidence-based communication techniques to encourage active participation in their healthcare and achievement of personal health goals
• Promote healthy lifestyle changes and self-management of chronic medical and behavioral health conditions
• Provide individualized health education related to chronic disease management, medications, preventive care, and wellness

Care Coordination

• Coordinate care across primary care providers, specialists, behavioral health providers, hospitals, skilled nursing facilities, pharmacies, and community organizations
• Facilitate timely access to medical, behavioral health, and community-based services
• Develop, implement, monitor, and update individualized Care Plans that reflect member-centered goals
• Ensure recommendations are communicated effectively across healthcare providers and care team members
• Coordinate physical health care management and care coordination activities with external healthcare providers

Medication Management

• Complete medication reconciliation for ECM members following hospitalizations, emergency department visits, transitions of care, medication changes, and other clinically appropriate encounters
• Collaborate with the member's Primary Care Provider and pharmacy to ensure medication accuracy and promote medication adherence
• Monitor medication alerts, treatment plans, and clinical notifications, ensuring appropriate follow-up

Clinical Oversight

• Review Comprehensive Health Assessments (CHA)
• Track and ensure completion of required assessments, screenings, Shared Care Plans, and documentation required by Managed Care Plans and DHCS
• Monitor medical and behavioral health outcome measures using the organization's care management platform
• Identify members requiring clinical intervention or escalation and collaborate with providers to address complex clinical needs

Transitional Care Management

• Ensure smooth transitions of care following emergency department visits, hospital admissions, skilled nursing facility stays, and other care transitions
• Coordinate discharge planning activities and facilitate timely follow-up appointments with Primary Care Providers and specialists
• Collaborate with hospitals, facilities, providers, and interdisciplinary team members to reduce avoidable readmissions and improve continuity of care

Clinical Consultation

• Serve as the clinical resource for Behavioral Health Care Managers, Community Health Workers, Care Coordinators, and other interdisciplinary team members
• Provide consultation regarding chronic disease management, medications, treatment plans, prevention strategies, and evidence-based nursing interventions
• Support interdisciplinary discussions involving complex member cases and clinical decision-making

Collaboration & Quality

• Participate in Systematic Case Reviews (SCR), interdisciplinary case conferences, and ad hoc clinical case reviews
• Foster a collaborative, respectful, and effective team environment through evidence-based communication and conflict resolution strategies
• Collaborate with providers and care team members to improve member outcomes and ensure high-quality, coordinated care
• Maintain accurate, timely, and compliant documentation within the electronic health record and care management platform
• Ensure compliance with Titanium Healthcare policies, DHCS regulations, Managed Care Plan requirements, and CalAIM ECM standards
• Participate in quality improvement initiatives, ongoing education, and organizational training
• Perform additional duties and special projects as assigned

Who You Are

• Possess strong clinical assessment and critical thinking skills
• Ability to interpret clinical information and develop appropriate nursing recommendations
• Knowledge of chronic disease management and evidence-based nursing practice
• Understanding of care coordination, population health, and value-based care principles
• Strong understanding of medication reconciliation and transitions of care
• Excellent communication, motivational interviewing, and relationship-building skills
• Ability to collaborate effectively within interdisciplinary teams
• Strong organizational, documentation, and time management skills
• Ability to prioritize multiple competing responsibilities in a fast-paced environment
• Commitment to delivering compassionate, culturally competent, person-centered care

Sensory Requirements

• Fluent in English (written and verbal), Bilingual in Spanish
• Ability to communicate clearly in-person, by phone, and electronically
• Adequate hearing and vision (with corrective devices if necessary) to conduct assessments and documentation
• Ability to identify problems and use logic and related information to develop and implement solutions
• Commitment to maintaining patient confidentiality and adhering to ethical standards in healthcare practice

Physical Activity

• Ability to lift, carry, push, or pull up to 20–25 pounds (e.g., laptop bag, forms, mobile equipment)
• Ability to climb stairs or navigate uneven terrain in community and home environments
• Ability to bend, reach, and conduct in-person visits in non-traditional environments
• Must be able to remain in a stationary position
• Must be able to move around the office and/or travel throughout community
• Ability to operate a vehicle and travel to meet with members around the community; attend meetings and events as required or requested

Environmental Conditions

• Work may occur in homes, shelters, outdoor settings, hospitals, or community organizations, which may include exposure to pets, smoke, odors, clutter or unsanitary condition, and varying temperature conditions
• Ability to maintain professionalism and safety in diverse environments
• Ability to work independently and carry out assignments to completion within the parameters of established policies and procedures

Technology Use

• Frequent use of computers, keyboard, and handheld/mobile devices
• Ability to type for extended periods
• Competent with computers, email, virtual platforms, electronic health records (