Registered Nurse (RN) – Street Medicine, Enhanced Care Management in San Bernardino, California at Wellness and Equity Alliance LLC

Wellness Equity Alliance is a national multidisciplinary health organization that designs and delivers integrated, community-based care for populations most impacted by health inequities. We do this through mobile and field-based models, providing medical care, behavioral health services, substance use treatment, harm reduction, and care coordination in nontraditional settings such as encampments, schools, reentry sites, and rural communities, as well as with sovereign tribal nations. Grounded in trauma-informed, culturally responsive, and data-driven practices, WEA combines clinical expertise, lived experience, and advanced population health analytics to reduce barriers to care, improve continuity, and strengthen local systems. We have partnered with more than 60 public agencies, managed care plans, and community-based organizations across the U.S. to implement scalable, sustainable programs that are advancing health equity and improving outcomes for historically marginalized populations.

We are known as Renegades, Rebels, Disruptors, and Dreamers. If that sounds like you, we want you on our team.

The Street Medicine Registered Nurse (RN) provides direct clinical care, health assessment, and care coordination to individuals experiencing unsheltered homelessness who are enrolled in Medi-Cal's Enhanced Care Management (ECM) benefit under CalAIM. This field-based role is part of a multidisciplinary care team, including nursing, advanced practice providers, behavioral health, community health workers, and a Lead Care Manager, delivering high-touch, in-person, whole-person care where members live.

The RN works alongside each member's Lead Care Manager to ensure services meet DHCS ECM Population of Focus requirements, specifically individuals experiencing homelessness and, where applicable, adults at risk of avoidable hospital or emergency department utilization.

Program: CalAIM Enhanced Care Management (ECM)

Work Setting: Field-based (encampments, shelters, riverbeds, vehicles, public spaces, and other locations where members reside), with limited office/clinic time

Schedule: May include evenings, weekends, and outreach shifts based on member need and street conditions

Duties are aligned to the seven DHCS-required ECM core service components.

Direct Clinical Nursing Care

• Perform comprehensive nursing assessments in field settings, including vital signs, physical exams, wound assessment, cognitive and mental status screening, chronic disease status, and functional status evaluation.
• Perform phlebotomy and specimen collection in field and outreach settings, ensuring proper labeling, handling, and transport per lab and infection-control protocols.
• Administer point-of-care testing (e.g., glucose, HIV/HCV rapid tests, pregnancy tests) as ordered and within scope of practice.
• Administer medications, immunizations, and injections as ordered, including directly observed therapy (e.g., long-acting injectables) where applicable.
• Provide wound care, dressing changes, and basic procedural support (e.g., suture/staple removal) under standing orders or APP direction.
• Implement treatment plans under the supervision and direction of the Advanced Practice Provider (NP/PA), monitor response to treatment, and relay clinical findings to the APP for orders and plan adjustments.
• Triage acute symptoms in the field and escalate to the APP, physician, or emergency services as clinically indicated.
• Perform medication reconciliation and support medication management and adherence (e.g., pill organizers, adherence packaging) for members with unstable housing and storage challenges.
• Maintain and restock the field medical bag/kit in accordance with clinical protocols and cold-chain requirements for medications and specimens.

Outreach & Engagement

• Conduct in-person street outreach to locate, engage, and build trust with unhoused individuals eligible for ECM.
• Obtain and document member consent to enroll in ECM per DHCS requirements.
• Re-engage hard-to-reach members using harm-reduction and trauma-informed approaches.

Comprehensive Assessment & Care Planning

• Contribute clinical input to each member's individualized care plan, addressing medical, behavioral health, and social needs.
• Identify and flag acute or urgent conditions requiring escalation to a higher level of care.

Enhanced Coordination of Care

• Coordinate with members' PCPs, specialists, behavioral health providers, hospitals, and pharmacies to ensure continuity of care.
• Communicate clinical findings to the Lead Care Manager, supervising APP, and care team, and participate in interdisciplinary care team (ICT) meetings.

Health Promotion

• Provide health education on chronic disease self-management, harm reduction, wound care, infectious disease prevention, and preventive care.
• Support member self-management goals documented in the care plan.

Comprehensive Transitional Care

• Support members transitioning from hospitals, emergency departments, or nursing facilities back to the street or interim housing to reduce avoidable readmissions.
• Ensure discharge instructions, medications, and follow-up appointments are understood and actionable for members without stable housing.

Member & Family Support

• Serve as a trusted clinical point of contact, providing culturally responsive, person-centered, non-judgmental care.
• Support member autonomy and choice, consistent with the voluntary nature of ECM.

Coordination of and Referral to Community & Social Supports

• In collaboration with the Lead Care Manager, refer and connect members to CalAIM Community Supports (e.g., housing transition/navigation, medical respite, recuperative care, sobering centers) and other social services.
• Document referrals and close the loop on outcomes.

Documentation & Compliance

• Document all member encounters, clinical findings, procedures, and services in the Electronic Health Record (EHR) in a timely and accurate manner, meeting DHCS documentation standards (outreach attempts, consent, assessments, care plans, ICT notes, clinical encounters, phlebotomy, point-of-care testing, medication administration, and wound care).
• Complete required ECM training per DHCS and managed care plan (MCP) contract requirements.
• Maintain a caseload within the organization's established care team ratios, adjusted for acuity and team composition per MCP guidance.
• Support the organization's Staffing and Capacity Reporting obligations to the MCP.
• Accurately record and submit all time worked, including meal and rest periods, in accordance with non-exempt status and California wage and hour law.

The following requirements apply with or without reasonable accommodation:

• Walk, stand, and navigate uneven outdoor terrain, encampments, and vehicles for extended periods.
• Work in conditions that include exposure to weather, unsanitary conditions, and unpredictable behavior. De-escalation training is provided.
• Carry field supplies and equipment (medical bag, phlebotomy supplies, wound care supplies, harm-reduction kits).
• Manual dexterity sufficient to perform phlebotomy and other clinical procedures in non-clinical, sometimes mobile settings.

• Active, unencumbered California Registered Nurse (RN) license.
• Current BLS certification (ACLS preferred).
• Demonstrated competency in phlebotomy and specimen collection.
• Experience using Electronic Health Records (EHRs) for clinical documentation, order tracking, and care coordination.
• Minimum 1–2 years of clinical nursing experience. Experience with unhoused populations, street medicine, community health, or public health strongly preferred.
• Experience or comfort working with individuals with serious mental illness, substance use disorders, and complex chronic conditions.
• Comfort working under the direction of and in close collaboration with Advanced Practice Providers in a field-based, protocol-driven care model.
• Valid California driver's license and reliable transportation for field-based work, or ability to travel via team vehicle.
• Ability to work in outdoor, non-clinical, and sometimes unpredictable environments.

• Bilingual/bicultural, reflecting the population served.
• Training or experience in trauma-informed care, harm reduction, motivational interviewing, and cultural humility.
• Experience with Medi-Cal managed care, care management, or CalAIM programs (ECM, Community Supports, Whole Person Care, or Health Homes Program).
• Experience supervising or collaborating with Community Health Workers (CHWs).
• Experience with point-of-care testing and mobile/street medicine clinical workflows.

• Person-centered, trauma-informed, and harm-reduction approach to care.
• Strong clinical judgment in low-resource, non-traditional care settings.
• Effective interdisciplinary collaboration and documentation discipline, including close coordination with supervising APPs.
• Cultural responsiveness and de-escalation skills.

Wellness and Equity Alliance is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other characteristic protected by law. Qualified applicants with arrest or conviction records will be considered for employment in accordance with the California Fair Chance Act and applicable local fair chance ordinances.