D-SNP Care Manager; RN; Hybrid Job Santa Barbara area,California USA,Nursing

Job Details:

Job Location:

Main Office - Santa Barbara, CA 93110, Position Type:
Full Time, Education Level: Associate's Degree, Salary Range: $ - $ Salary/year, Travel Percentage:
None, Job Category:
Medical Management, Central Coast Salary Range:$107,053 - $160,580 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 is responsible for managing a caseload of Dual Eligible Special Needs Plan (D-SNP) members with complex medical, behavioral health, functional, and psychosocial needs. Utilizing clinical judgment, evidence-based practice, and a person-centered approach, the D-SNP Care Manager RN conducts comprehensive assessments, develops and implements individualized care plans, coordinates interdisciplinary care, and supports members across the continuum of care.

This role serves as a primary clinical resource for high-risk members, working collaboratively with providers, caregivers, community organizations, and internal departments to improve health outcomes, address barriers to care, reduce avoidable utilization, and ensure compliance with D-SNP Model of Care requirements. The D-SNP Care Manager RN requires advanced clinical expertise, knowledge of Medicare Advantage and Medi-Cal regulations, strong communication skills, and a commitment to delivering integrated, whole-person care to a vulnerable population.

Core

Functions

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

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.

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…