Care Manager

Aria Community Health Center•Lemoore, CA

21d•$23 - $24

About The Position

The Care Manager assists Clinic Operations and provides care coordination support to Aria Community Health Center’s Patient Centered Medical Home Care Management Program for patients in Tulare, Fresno, and Kings counties. The role identifies and coordinates patient needs within ACHC and with outside providers to improve health outcomes. Patient needs may include complex health conditions, mental health diagnoses, shelter concerns, financial instability, extreme poverty, transportation, or food insecurity. Chart review is under the direct oversight of Clinic Operations. The Care Manager conducts outreach to potentially eligible patients and works with eligible patients and care coordinators to meet established goals using patient-centered approaches. Motivational interviewing, trauma-informed care, and persuasion skills are fundamental to the role. The position includes assessments, individualized care planning, patient advocacy, referrals and connections to services, health promotion and self-management education, telephonic follow-up, program enrollment and documentation, and participation in multidisciplinary care teams.

Requirements

At least one year of experience in a clinic or healthcare setting.
Bilingual English/Spanish.
May substitute one year of experience for a Nursing Assistant, Medical Assistant, or Home Health Aide certificate or license.
Basic understanding of best practices or lifestyle recommendations for common complex conditions, including asthma, depression, diabetes, heart conditions, and hypertension.
Basic understanding of government and nonprofit resources, including public assistance, rent and utility assistance, and food distribution.
Ability to work cooperatively and flexibly on multidisciplinary teams; exercise appropriate judgment and decision-making; and communicate effectively in interpersonal, verbal, and written settings.
Ability to engage patients and providers by telephone, in person, and by email.
Organization, prioritization, and time-management skills; ability to work under pressure, meet deadlines, establish priorities, and adapt to change.
Ability to independently locate resources and collaborate to solve barriers to care.
Ability to read, understand, and follow oral and written instructions, internal policies and communications, and applicable local, state, and federal regulations.
Proficiency with Microsoft Office Suite and Electronic Health Record programs.
Ability to work in a regulatory environment involving state and federal oversight and payer contracts.
Respect for others and acceptance of individual, social, and cultural traits.
Ability to travel to and attend professional meetings, conferences, trainings, and clinic sites.
Ability to meet the position’s hearing, speaking, vision, cognitive, mobility, and motor-function demands, with or without reasonable accommodation, including occasional lifting and carrying of items up to 10 pounds and frequent standing, sitting, bending, and reaching.

Nice To Haves

Associate degree in Health Sciences, Human Services, or a closely related field.
Experience with county resources.
Knowledge and experience in motivational interviewing.
Experience working with traditionally marginalized populations.

Responsibilities

Conduct initial and ongoing assessments to identify medical, mental health, substance use, social, housing, and functional needs.
Carry a caseload consistent with PCMH guidelines.
Develop individualized, whole-person care plans with input from patients and providers.
Advocate for patients in multidisciplinary team meetings and with insurance carriers, outside health providers, social workers, and resource providers.
Connect patients to services that address barriers to health, including shelter, transportation, food access, and in-home care.
Use motivational interviewing and trauma-informed care practices to support patients in meeting goals established by the Clinical Team.
Engage patients who meet program eligibility requirements.
Provide health promotion and self-management training to patients and their families.
Conduct regular telephone outreach and follow-up with patients.
Complete comprehensive social determinants of health assessments.
Complete enrollment screening and documentation, Health Action Plan reports, and other necessary reports.
Obtain required Care Management enrollment consents.
Function as a patient advocate and promote wellness and prevention.
Verbally present patient cases to the multidisciplinary team and distribute health promotion materials.
Maintain accurate, timely documentation, including enrollment, assessments, progress notes, resource access applications, releases of information, and other required forms.
Support other Care Managers with delegated tasks.
Protect the privacy and security of Protected Health Information in accordance with ACHC policies and procedures.
Perform other assigned duties, including verifying insurance eligibility and submitting treatment authorizations.