ECM Lead Care Manager

St Johns Community Health•Gardena, CA

8h•Hybrid

About The Position

Under the direction of the ECM Program Manager and Lead Coordinator, the Lead Care Manager will outreach and enroll clients in enhanced care management. This role involves working with leadership, providers, and managed care plans to determine the needs of high acuity, vulnerable patients. Responsibilities include providing basic housing assistance, intensive case-management tailored to the patient, developing a care/service plan, and providing linkages to medical, psychiatric, social, educational, and other services as needed. The Lead Care Manager will also collaborate with Community Supports Program staff to deliver team-based, patient-centered care management for homeless and at-risk-of-homelessness patients. Care managers will work with medical and/or behavioral providers and patients to implement and perpetuate treatment and chronic disease self-management for enrolled patients, both within and outside the clinic. This includes developing and maintaining Care Management Plans, reviewing them with the team for compliance, assisting with crises within their teams and caseloads, coordinating support services, and reviewing progress toward patient goals. The role also involves completing scales and assessments as directed and being responsible for billing as required by managed care plans and DHCS.

Requirements

Familiar with working with managed care plans and / or Medi-Cal
Experience working with an Electronic Health Record system; eCW preferred.
Must be able to work independently and alongside a team in assisting clients meeting their goals.
Available to work Monday-Friday, and some Saturday’s when needed. As well evenings to program and clinical needs.

Nice To Haves

Bachelor's Degree
Bilingual English & Spanish

Responsibilities

Conduct assessments and coordinate all aspects of care, transportation, referrals, and scheduling for patients.
Promote and aid patient in establishing self-management skills, linking them to resources in the community including public benefits and social services.
Crisis management and patient advocacy
Maintain patient file/record of appointments, services, follow ups and assessments based on DHCS requirements of ECM Program and SJCH requirements.
Liaison between client and community resources, medical / specialty offices and / or when support is needed.
Work with Medical providers, specialists, therapists, social workers etc. internally and externally, to determine health priorities and develop managed care plans that includes smart goals, and actions to resolve barriers and access to services.
Attend on going staff meetings, clinical and non-clinical case conferences, team meetings and trainings per program needs.
Strengthens the individual/family’s ability to access and meet education, health and social/behavioral service needs.