Enhanced Care Management Care Coordinator

Step Up • Victorville, CA

8h • $25 - $28 • Onsite

About The Position

As a key part of CalAIM, Enhanced Care Management (ECM) is a statewide MediCal benefit available to select “Populations of Focus" that will address clinical and non-clinical needs of the highest-need enrollees through intensive coordination of the member’s health, wellness and an umbrella of services related to enrollee’s overall progress of care. Beneficiaries will have this single care coordinator who will strategize care and care services, which include physical, behavioral, developmental, and social services delivery systems, making obtaining care effective and efficient. Providing in-person, field-based services, ECM staff will meet beneficiaries wherever they are – on the street, in a shelter, in their doctor's office, or at home. Under the supervision of the ECM program manager.

Requirements

• AA degree or equivalent.
• 2 years’ experience working in community outreach, homelessness, and/or a behavioral health or substance use disorder program.
• A valid California driver’s license and clean driving record.
• A reliable vehicle and valid automobile insurance is mandatory, as automobile travel is required in the Inland Empire either by personal or company vehicle.
• A clean report Department of Justice background check.

Nice To Haves

• Knowledgeable and skilled in Evidenced based communication such as Motivational Interviewing or similar empathy-based communication strategies.
• Able to sufficiently engage with members and healthcare providers in a variety of settings such as on the phone, at member’s homes, streets if homeless, in hospitals and other health settings.
• Ability to develop relationships with community members and leaders, including in the faith-based community.
• A high degree of skillful decision-making and judgement, in an autonomous position, including knowing when to consult with the team, supervisors, and experts.
• Understanding of and sensitivity to mental health conditions and addictive disorders.
• Understanding of and sensitivity to multicultural communities.
• Awareness of the impact of unmitigated bias, and judgement on health; a commitment to addressing both.
• Understanding of, and a commitment to, high performing team practices.

Responsibilities

• Provide high quality, effective care management to ECM members.
• Provide field-based services including outreach and face-to-face engagement focusing on members’ present health goals, concerns, and needs.
• Address present mental health behaviors and coordinate member’s care such as appointment scheduling and referral management, resource linkages, transportation, and/or durable medical equipment requests.
• Collaborate care with the member’s primary care physician (PCP) and ensure that both members and PCP participate in the development of care plan and to strategize with the ECM interdisciplinary team and management.
• Work collaboratively with enrolled members’ families, and other professionals including the designed care team, health professionals and organizations in the community to ensure quality of care for members, seamless transition of care, and facilitation of services.
• Use relationship-based strategies to engage members in care as well as motivational interviewing or similar empathy-based strategies.
• Maintain strong organizational skills, computer data entry and other administrative program expertise to submit required documents, visits notes, care plans, demographics, legal documents and other mandatory files into provider portals and Step Up program systems on time and on a daily basis.
• Conduct basic health data and submit health outcomes such as labs, discharge plans and other health related records.
• Act as a mandated reporter and advocate for the health, protection and safety of the enrolled member.
• Complete and become proficient in each Healthcare Plan’s Electronic Health Record to ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards.
• Ensure the privacy and security of the PHI as outlined in Step Up’s policies and procedures relating to HIPAA compliance, including attending annual compliance training.
• Participate in outreach and engagement efforts to enroll referred members in ECM.
• Assist Members in navigating the healthcare system, helping Members successfully participate in their medical and/or behavioral health care by overcoming barriers to care, sharing information on barriers with the PCP to improve care and outcomes.
• Assist with members’ transition upon discharge from medical or psychiatric hospitals by coordinating with hospital discharge planning and being supportive in plan transitions.
• Collaborate within the hospital to connect with members before they are released to start relationship building.
• Navigate housing, routinely revisit the care plan, and support members in attending follow-up appointments.
• Play a key role in crisis response teams that provide community-based alternatives to justice involvement.
• Deliver information about health and wellness in ways that the community can easily understand and provide information on ECM Member benefits and services.
• Provide advocacy on behalf of ECM Members in the home, the community, and in provider organizations.
• Transport and attend appointments to ensure successful completion of and outcomes of each health-related goal or task.
• Engage with members in a manner that utilizes evidence-based approaches, such as motivational interviewing, that promote collaboration between the member and his or her health.
• Assist Step Up ECM and other Providers understand the culture, norms, beliefs and preferences of the Members and their community.
• Assist with the coordination of medical and behavioral health access issues with Step Up programs, PCP offices, and specialists.
• Participate in all formal and informal trainings to gain continued knowledge on medical conditions including treatments and evidence-based for treatment always staying within scope.
• Collaborate on Member care issues with other Step Up’s ECM team in scheduled systematic case reviews and ad hoc case reviews and consult with Nurse Care Coordinator III, and SCII before taking any action that is clinical in nature.
• Model the highest ethical behavior in relationship with co-workers, supervisor, members, provider, and colleagues in the community and within Step Up’s ECM.
• Promote a collaborative and effective working environment with the Step Up’s ECM team by engaging in evidenced based communication strategies when discussing responsibility/sharing of tasks, effective resolving conflict as they arise and collaborating on member case discussions.
• Build and maintain a positive working relationship with members and providers including by not limited to communication via in-person, over the phone, and through digital means, such as email and fax.
• Model commitment to continuous quality improvement by engaging in quality improvement initiative and projects such as by identifying and assessing gaps and by identifying, developing and testing new practices for improving the outcomes of the ECM.
• Participate in staff meetings, trainings, individual supervisions, and other activities as needed or directly by the Step Up’s ECM team.
• Maintain documentation for each member contact as instructed and within the program timelines.
• Complete CHA: Due immediately upon enrollment, annually, and condition changes.
• Obtain members’ Blood Pressures: Due Every 60 days.
• Complete member’s PHQ-9: Due every 30 days.
• Complete Care Plans: Due upon enrollment, and updated Care Plans are due every 90 days.
• Transition of Care Discharge (TOC): Due within 7 days of the member’s admission and discharge from an inpatient hospital stay.
• Submit billable notes to provider portals, Step Up electronic health records (Welligent) and maintain member’s charts and profiles.
• Keep an accurate and up to date calendar to reflect daily schedule.
• Maintain caseload and census daily.
• Report emergencies, urgent care needs, crisis, etc. to Step Up management necessary documentation.

Benefits

• Opportunities for growth and professional development.
• Generous paid time off (13 paid holidays, 10 days of EPTO, 12 sick days).
• Competitive salary and benefits package.
• Health, dental, vision, Aflac, and life insurance $25,000.00
• 403(b) retirement plan available on the first day of work.
• Step Up matches 3% of the 6% the employee contributes to the 403(b) retirement plan after working 1000 hours.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree