### About Us
We are a community-focused health and care partner dedicated to enhancing the health and well-being of individuals, particularly in Black and Brown communities. Our collaborative team of local physicians, nurses, and caregivers is committed to delivering personalized care that goes beyond merely addressing symptoms. We believe that understanding the unique race, culture, and environment of our Family Members is vital for achieving improved health outcomes. Our mission is to empower our Family Members, providers, and caregivers, making health and care accessible and manageable every day.
### Candidate Qualifications
We Are Seeking Individuals Who Possess The Following Qualifications

• Education**:
• An active Registered Nursing (RN) license in California.
• A Bachelor of Science in Nursing (BSN).
• Experience**:
• At least five years of relevant clinical experience.
• A minimum of three years of care management experience in health plans, home health, or hospice settings is preferred.
• Entrepreneurial Spirit**:
• Ability to tackle longstanding gaps in care delivery for Black and Brown populations and drive innovative solutions independently.
• Communication Skills**:
• Strong verbal and written communication abilities to present concepts clearly and effectively.
• Relationship Building**:
• Proven ability to cultivate and maintain relationships with patients, community leaders, and external stakeholders.
• Cultural Fit**:
• Good judgment, strong ethics, and a collaborative mindset are essential. Candidates should thrive in a dynamic, fast-paced environment.

### Role Overview
As part of our team, individuals will report to the Director of Clinical Operations and be responsible for providing strategic insights and evidence-based analysis to guide decision-making. The core values that guide our work include Trust, Empathy, Commitment, Humility, Creativity, and Community Mindedness.
### Key Responsibilities

• Collaborate with an interdisciplinary team to ensure high-quality outcomes for members and families managing chronic diseases.
• Develop care pathway templates tailored to condition risk levels and member actions.
• Create and implement Member Action Plans emphasizing high-risk chronic conditions.
• Conduct in-home or telehealth assessments as required.
• Maintain active communication with members and caregivers through text and phone following member alerts and monitoring remote patient tools.
• Facilitate care coordination, chronic disease management, and interdisciplinary collaboration in accordance with policies and procedures.
• Work closely with patients and care teams to refine Member Action Plans based on patient and caregiver needs.
• Engage patients in actively managing their health, medications, and treatment plans and facilitate referrals to community organizations.
• Utilize evidence-based guidelines to identify care gaps and assess the need for in-home services.
• Utilize electronic medical records and care management platforms for documentation compliance and coordination activities.
• Participate in team rounds to contribute to program development and process improvement.
• Reassess Member Action Plans following patient discharge.
• Adapt priorities effectively to manage patient care loads.
• Collaborate with the interdisciplinary team on patient care planning and facilitation.

### Additional Duties

• **Leadership**: Drive the development and execution of strategies that enhance clinical practice value and support effective implementation within the team.
• **Strategy**: Develop business strategies aimed at improving member outcomes, optimizing operational efficiency, and identifying market opportunities.
• **Collaboration**: Ensure seamless integration of clinical capabilities by working collaboratively with other business divisions.
• **Knowledge**: Share expertise in clinical solutions, prioritizing high-quality medical care and care management approaches.
• **Culture**: Promote a productive, inclusive, and safe working environment for the clinical team and broader organization.

### Working Environment and Physical Requirements
This role requires both in-home and office-based work, necessitating regular travel for home visits, physician offices, hospitals, and community partners, which may occur in various weather conditions. Office tasks are conducted in a climate-controlled indoor setting.
Candidates should be prepared for frequent travel via car or public transportation, and effective communication with customers, vendors, and colleagues is essential, even in challenging situations. Regular use of telephone and email for communication is required, and individuals must be able to sit for extended periods. There may be occasional lifting of up to 30 lbs., and strong manual dexterity is necessary for operating common office equipment. Good reasoning skills will be critical for understanding and utilizing management reports and other relevant documentation.
Employment Type: Full-Time