Case Manager - ECM (Enhanced Care Management) (4082)

MERCY HOUSE•Santa Ana, CA

4d•$23 - $24

About The Position

The Enhanced Care Management (ECM) Lead Care Manager is responsible for coordinating all covered medical and non-medical supportive services the member needs, including physical, behavioral, dental, developmental, oral health, long-term services and supports (LTSS), Specialty Mental Health Services, Drug Medi-Cal/Drug Medi-Cal Organized Delivery System services, Community Supports, and other services that address social determinants of health (SDOH) needs, regardless of setting. The ECM Lead Care Manager will work closely with the CalAIM Community Supports Program staff to provide team-based, patient-centered care for clients experiencing homelessness and at risk of homelessness.

Requirements

Bachelor’s Degree in Social Work (or related field) with experience working in chemical health, mental health, and co-occurring disorders are preferred
Persons with less than a BA/BS degree but with at least 2 years of direct life experience working with long-term homeless, low-income, and diverse populations and have a working knowledge of mental health and addiction issues are welcome to apply
A valid CA driver’s license, proof of insurance and a reliable vehicle is required. Comfortable with utilizing your own vehicle to conduct home visits, visiting clients at shelters, meeting clients out in the community etc.
Ability to work effectively with a diverse population; plan, organize and prioritize duties; crisis intervention as needed; clearly communicate information and instructions verbally and in written form; maintain a positive, professional, and safe environment while on duty; and establish and maintain effective working relationships with others
Dependability, responsibility, and the ability to communicate effectively and respectfully are mandatory skills
Knowledge of how to use Microsoft programs and computer literacy are required
Ability to lift items weighing up to 50 pounds
Prolonged periods of sitting at a desk and working on a computer

Nice To Haves

Preferred skills related to outreach and engagement, care planning, care coordination, health promotion, transitional care support, member and family education, and social services coordination
Preferred minimum of 1 year of experience in care coordination and case management for the following populations: Individuals/Families experiencing homelessness, Individuals at risk for avoidable hospital stays (High Utilizers), Individuals with Serious Mental Health and/or SUD, Adult Nursing Facility Residents Transitioning to the Community, Adults with intellectual or developmental disabilities
Experience with HMIS Data Entry/CalOptima Health strongly preferred
Preferred experience with Housing First and Harm-Reduction strategies, Motivational Interviewing, Patient-Centered and Trauma-Informed Care, Crisis Intervention & Prevention strategies
Preferred experience in engaging and assisting individuals/families with acute mental illness & substance use to access/navigate health care as well as other needed services
Fluency in Spanish is of significant value

Responsibilities

Maintain a minimum caseload of 17-25 individuals and meet with members as needed to complete Health Needs Assessments, Care Plans, which include short- and long-term measurable goals
Engage, outreach, and enroll eligible ECM members in services and help address barriers
Offer services where the member lives, seeks care, or finds most easily accessible, within CalOptima Health guidelines
Support and engage members in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation when needed for medical appointments, accompanying members to critical appointments, and identifying and helping to address other barriers to member engagement in treatment
Accompany members on office visits as needed and according to CalOptima Health guidelines
Advocate on behalf of the member with healthcare professionals and work with hospital staff on discharge plans
Collaborate with area hospitals, behavioral health providers, specialists, dental providers, providers of services for Long-Term Services of Support (LTSS), and other associated entities such as Community Supports, as appropriate, to coordinate member care
Use motivational interviewing and trauma-informed care practices
Monitor treatment adherence (including medication)
Provide health promotion and self-management training to enrolled ECM members
Report ECM patient progress, concerns, and needs to the multidisciplinary team to improve patient care
Work as a Mercy House team member with all staff and volunteers to implement the mission and core values of the agency
Attend regular internal and external agency meetings
Work as part of a team to plan and develop resident programs
Work in a team environment, fast-paced environment, be flexible, adaptable to sudden changes, trustworthy, reliable, and empathetic
Communicate effectively with diverse populations
Keep accurate, up-to-date documentation on all clients, including but not limited to Health Needs Assessments and Care Plans
Assist with all data collection systems
Assure deadlines are met
Utilize computers and appropriate software (e.g., Microsoft Word, Outlook, Excel, PowerPoint) and/or specific systems applicable to the position
Respond to calls and emails in a timely manner
Perform tasks independently and prioritize workload