Bilingual Spanish RN, Care Management (Riverside)

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. **\*Position will work remote & in the field about 25% of the time in Riverside, CA & the surrounding areas\*** **The Job** The Registered Nurse (RN) – Care Management is a clinically accountable role responsible for delivering high-touch, person-centered care management to members with complex medical needs who cannot be effectively supported through telephonic care management alone. The RN conducts in-home and telephonic assessments, develops and manages individualized care plans, educates members and caregivers on disease processes and self-management, and collaborates with an interdisciplinary care team to stabilize risk and improve health outcomes. The RN serves as the clinical lead, coordinating care across providers and settings to promote safe, effective, and timely care. **You Will** - Conduct comprehensive clinical, functional, and environmental assessments in members’ homes and via telephonic encounters, based on clinical risk and acuity. Identify clinical, functional, medication, caregiver, and environmental risks that may impact member stability or safety. - Work collaboratively with Social Workers, Community Health Workers, Care Coordinators, and other interdisciplinary team members to address medical, psychosocial, and environmental barriers to health. Participate in case reviews, huddles, and interdisciplinary discussions to support coordinated, member-centered care. - Develop, implement, and regularly update individualized care plans with measurable goals focused on member priorities and health outcomes by evaluating assessment findings against evidence-based guidelines, clinical reasoning, and best practices. Integrate clinical insights and community standards to develop comprehensive and effective care strategies. - Provide disease-specific education, coaching, and self-management support to members and families, using teach-back to confirm understanding. - Support medication safety through medication reconciliation, adherence assessment, and coordination with providers and pharmacy resources when needed. - Coordinate care with primary care providers, specialists, hospitals, skilled nursing facilities, home health, and community resources to ensure continuity of care. - Demonstrates organizational, decision-making, critical thinking, and multi-tasking skills as demonstrated by problem solving and achieving successful member outcomes. Adhere to all SNP Model of Care requirements and procedures. Complete timely and accurate documentation across multiple computer systems, including; care plans, service plans, and progress notes as necessary within established timeframes. - Manage transitions of care following emergency department visits, hospitalizations, or facility discharges, including follow-up, risk mitigation, and education on red-flag sym…