Lead Care Manager

  Lead Care Manager (Enhanced Care Management Program) Status: Non-Exempt, Full-Time Department: ECM Reports To: ECM Site Manager or designee Work Schedule: 8-hour shift, Monday through Friday. However, flexibility is required due to the nature of business. The schedule may be changed as needed. POSTION SUMMARY: The Enhanced Care Management (ECM) Lead Care Manager is responsible for coordinating care and services among the physical, behavioral, dental, developmental, and social service delivery systems ensuring individuals receive the right care at the right time and become, or remain, able to live successfully in their communities. The ECM Lead Care Manager supports program growth by making initial contact in engaging with potential patients, providing information about Enhanced Care Management services, and enrolling patients. The ECM Lead Care Manager will determine eligibility, complete enrollment assessments and work with our program partners to oversee the eligible patient population for the ECM Program. ESSENTIAL DUTIES AND RESPONSIBILITIES ⦁ Accompany MCP Member to office visits, as needed and according to MCP guidelines. ⦁ Connect MCP Member to other social services and supports needed. ⦁ Educate MCP Members about MCP Member benefits, including crisis services, transportation services, etc. ⦁ Distribute health promotion materials. ⦁ Advocate on behalf of MCP Members with health care professionals ⦁ Use motivational interviewing, trauma-informed care, and harm-reduction practices. ⦁ Work with hospital staff on discharge plan ⦁ Contact MCP Member to schedule in-person visit with the contract provider. ⦁ Responsible for accurate and timely documentation which includes but is not limited to program enrollment, assessment, updated activity/progress notes, resource access applications, releases of information, and any other forms necessary to document services. ⦁ Provides ongoing monitoring of the Targeted Engagement List (TEL). ⦁ Conducts regular telephonic outreach and follow-up with ECM Patients. ⦁ Complete comprehensive Intake assessments. ⦁ Assist members in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), Cal Fresh, cash aid, and housing. ⦁ Assigns Patients to the appropriate ECM Care Team members based on risk category and available clinical data for ECM engagement activities. ⦁ Carries a caseload of 50 patients and assists with any health or social needs they may have until the Patient can maintain their overall needs on their own. ⦁ Supports other ECM Care Team members with delegated tasks. ⦁ Responsible for assisting patients with care coordination needs, including, but not limited to, referral support, community resource connection, health care navigation, and tracking all referrals in the designated logs and/or electronically. ⦁ Responsible for engaging with patients, both in-person and on the phone, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) that promote collaboration between the Patient and their medical/behavioral health team, as well as increase the Patient’s sense of control over their whole health. ⦁ Assess for substance use recovery support services and treatment options. ⦁ Forms and fosters relationships with housing agencies and permanent housing providers, including supportive housing providers. ⦁ Assists with coordinating medical and behavioral health access issues with PCP offices, Specialists, and Ancillary Services. ⦁ Ensures the privacy and security of Protected Health Information (PHI) as outlined in the policies and procedures relating to HIPPA compliance. ⦁ Ensures documentation is accurate and in compliance with regulatory requirements and accreditation standards. ⦁ Meet or discuss with patients any and all aspects of the referral process as needed or requested by the treating provider. ⦁ Complete face-to-face interviews with the Patient to obtain detailed information related to social service needs. ⦁ Schedule appointments with community-based resources with patients. ⦁ Collaborates on Patient care issues with other ECM Care Team members, participates in systematic case reviews, and consults with other ECM Care Team members. ⦁ Uses relationship-based and motivational interviewing strategies to engage Patients in Care. ⦁ Assists with arranging transportation and completion of durable medical equipment requests. ⦁ Coordinates with ECM Patients in the most easily accessible setting ⦁ Positively impact patient experience by demonstrating values of Transforming Care including, but not limited to, courteous and helpful behavior and a commitment to accuracy. ⦁ Other duties as assigned, including, but not limited to verification of insurance eligibilities, submission of treatment authorizations, and other duties as assigned. QUALITY MANAGEMENT & RECORD KEEPING ⦁ Contribute to the success of the organization by participating in quality improvement activities. ⦁ Document as necessary in required Electronic Medical Record portals and Managed Care Plan portals for all care coordination and other services or teaching provided in a timely manner. ⦁ Prioritizes activities according to intensity, need, and required follow-up. REQUIREMENTS ⦁ Effective written and verbal communication skills ⦁ Organization/Time management skills ⦁ Ability to think critically, solve problems creatively, and effectively assist clients in demanding situations. ⦁ A positive attitude, desire to learn and grow and aspirations to lead. ⦁ A focus on the growth and well-being of people and the communities to which they belong. ⦁ Excellent verbal, written and interpersonal communication skills. ⦁ High level of proficiency in web-based systems, real-time communication systems (i.e., chat), Microsoft Office, and other Client Record Management systems. ⦁ Familiarity and experience in the areas of community outreach, behavioral health, and working with high-risk populations. ⦁ Equivalent combination of education, training, and work experience to demonstrate the ability to perform the above tasks. ⦁ CA driver’s license and proof of car insurance are required. KNOWLEDGE AND ABILITY: ⦁ Work and communicate effectively with staff, families, community agencies, and professionals. ⦁ Perform crisis intervention strategies. ⦁ Communicate effectively orally and in writing. ⦁ Work effectively under stress and conflict. ⦁ Exercise appropriate judgment and decision making. ⦁ Be flexible and adaptable in any given situation. ⦁ Work as a member of a team. ⦁ Be well organized, flexible, and self-disciplined. ⦁ Knowledge of medical terminology. ⦁ Computer skills, including familiarity with spreadsheets, databases, scanning, printing, and faxing. ⦁ Effective communication and organizational skills. ⦁ The ability to interact effectively with clinic personnel, patients, and community-based organizations. ⦁ Highly skilled interpersonally, with excellent teamwork and relationship skills. ⦁ Knowledgeable about evidenced based communication, such as

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