D-SNP Care Manager (RN) - Hybrid

Central Coast Salary Range: $104,340 - $156,510 Annually

Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.

Job Summary

The D-SNP Care Manager RN requires advanced clinical judgment, knowledge of Medicare Advantage and Medi-Cal regulations, strong communication skills, and a commitment to delivering person-centered, integrated care to a vulnerable and high-risk population. The core functions of the D-SNP Care Manager RN role:

• Conduct Comprehensive Member Assessments
  Perform thorough assessments of members’ medical, behavioral, functional, and psychosocial needs to identify risk factors and inform individualized care planning.

• Develop and Implement Individualized Care Plans
  Create, monitor, and update person-centered care plans in alignment with the D-SNP Model of Care, ensuring services are timely, appropriate, and cost-effective.

• Coordinate Integrated, Interdisciplinary Care
  Collaborate with members, families, providers, and care teams to ensure seamless communication, care transitions, and access to necessary services and community resources.

• Promote Health Outcomes and Reduce Utilization Risks
  Address barriers to care, reduce avoidable hospitalizations and emergency room visits, and support members in achieving their optimal health outcomes through proactive care management.

Duties and Responsibilities

1. Conduct Comprehensive Member Assessments

• Complete comprehensive assessments of each member, including physical, behavioral, social determinants of health, functional status, caregiver resources, and formal/informal support systems.

• Complete timely Health Risk Assessments (HRA).

• Triage members based on clinical need and risk, referring to appropriate care settings, community-based services, or other programs (e.g., palliative care, behavioral health, health education).

• Possibly perform at least one face-to-face visit annually at the member's residence or preferred location.

• Maintain knowledge of and compliance with CMS, DHCS, Medi-Cal, and internal policies related to D-SNP care coordination and documentation requirements.

2. Develop and Implement Individualized Care Plans

• Identify member strengths, preferences, risks, barriers, and goals to develop and maintain individualized, person-centered care plans in partnership with the member/caregiver and the Interdisciplinary Care Team (ICT).

• Develop and update Individualized Care Plans (ICP).

• Monitor and evaluate members’ progress toward care plan goals, reassess as needed, and identify/address barriers impacting goal achievement.

• Develop self-management plans that proactively reduce risk of exacerbation or acute episodes, supporting members in achieving the least restrictive level of care.

• Collaborate with PCPs and specialists electronically and/or by phone to integrate evidence-based guidelines, preventive care, and quality metrics into care plans.

• Educate members and caregivers about available benefits, community services, and long-term services and supports (LTSS).

• Document all assessments, care plans, interventions, member interactions, and progress notes accurately and timely in the care management system, in compliance with regulatory and organizational policies.

3. Coordinate Integrated, Interdisciplinary Care

• Coordinate and participate in care conferences and ICT meetings to enhance communication and promote continuity of care.

• Convene and actively participate in ICT meetings.

• Coordinate with Medi-Cal Community Supports providers, transportation vendors, and internal transportation teams to arrange and monitor services that address members’ medical, functional, and social needs, supporting adherence to care plans and reducing barriers to care.

• Collaborate with Quality Improvement, Pharmacy, Utilization Management, and Health Education teams to address member needs holistically.

• Participate in case reviews, rounds, and case presentations at ICT and other interdisciplinary meetings.

• Build and maintain supportive relationships with members, their families and caregivers, primary care providers (PCPs), specialists, and all providers of care to promote trust, engagement, and collaboration.

• Serve as an advocate for members, ensuring care aligns with their preferences, cultural values, and stated goals.

4. Promote Health Outcomes and Reduce Utilization Risks

• Manage a panel of D-SNP members with complex medical, functional, cognitive, behavioral health, and psychosocial needs, ensuring delivery of high-quality, person-centered care aligned with the D-SNP Model of Care.

• Educate members and caregivers on chronic disease self-management, preventive health, medication adherence, and use of appropriate healthcare resources.

• Proactively identify and address gaps in care, including preventive screenings, medication management, and referrals to behavioral health and community resources.

• Manage transitions of care across settings.

• Coordinate care transitions to ensure safe and effective discharges from hospitals, skilled nursing, or other facilities, working closely with facility staff, PCPs, and the member/family.

• Support and participate in internal audits, data collection, and quality improvement initiatives aimed at improving care coordination, member outcomes, and regulatory compliance.

• Protect member confidentiality and comply with HIPAA, privacy regulations, and organizational policies.

• Other duties assigned in support of departmental and organizational goals.

Knowledge/Skills/Abilities

• Clinical Expertise: Strong clinical knowledge of adult chronic conditions, complex co-morbidities, functional and cognitive decline, and behavioral health issues common in D SNP populations.
• Person Centered Care & Cultural Sensitivity: Excellence in customer service and patient engagement; ability to interact effectively with members, caregivers, interdisciplinary care teams, and community agencies with diverse backgrounds, values, and cultural beliefs.
• Comprehensive Assessment Skills: Ability to assess medical, behavioral, functional, psychosocial, and social determinants of health needs to create individualized, person centered care plans.
• Critical Thinking & Problem Solving: Uses conflict resolution, negotiation, and creative problem solving skills to overcome barriers to care and support member self management.
• Communication: Excellent verbal and written communication skills for members, families, providers, and internal teams; ability to compose professional, grammatically correct correspondence, documentation, and care plans.
• Care Coordination & Collaboration: Ability to coordinate care across settings, convene and participate in interdisciplinary care team (ICT) meetings, and partner with PCPs, specialists, community supports, and transportation services to support holistic care.
• Regulatory Knowledge: Familiarity with CMS and DHCS requirements for D SNPs, including Model of Care elements, Health Risk Assessments, individualized care planning, interdisciplinary care teams, transitions of care, and member engagement standards.
• Quality Improvement Orientation: Understanding of quality metrics (e.g., STAR, HEDIS), preventive care guidelines, and performance improvement processes relevant to D SNP populations.
• Documentation & Systems Proficiency: Proficient in using electronic medical records (EMR), care management platforms, Microsoft Office (Word, Excel, Outlook), and internal tracking tools for timely and accurate documentation.
• Autonomy & Accountability: Demonstrates initiative and ability to work independently while collaborating effectively in a cross functional, team oriented environment.
• Time Management & Prioritization: Ability to meet deadlines, manage competing priorities, and complete D SNP required activities within specified timeframes.
• Adaptability & Influence: Flexible, open to change, and skilled in building consensus and influencing individual and group decision making.
• Member Advocacy: Commitment to empowering members to actively participate in their care, promoting independence and improved health outcomes.

Education and Experience