ECM Lead Care Manager

St Johns Community Health•Gardena, CA

2d•Hybrid

About The Position

Under the direction of ECM Program Manager and the Lead Coordinator, the Lead Care Manager will outreach and enroll clients in enhanced care management. Will work with leadership, providers, and managed care plans to determine the needs of high acuity, vulnerable patients. Providing basic housing assistance, patient tailored intensive case-management, developing a care/service plan; provide linkages to medical, psychiatric, social, educational, and other services as needed. Will also work with the Community Supports Program staff to provide team-based, patient-centered care management for homeless and at-risk of homelessness patients. Care managers are to work with medical and/or behavioral providers and patients to implement and perpetuate treatment and chronic disease self-management for patients enrolled in ECM within as well as outside of the clinic. Will develop and maintain Care Management Plan’s and review with the team for compliance. Assist with crises within their teams, and their caseload. Coordinate support services and reviews progress toward goals for patients. Completes scales and assessments as appropriate, needed and as directed by Lead Coordinator, Program Manager and or Director of ECM. Will also be responsible for billing as part of requirements per managed care plans and DHCS.

Requirements

Bachelor's Degree (Preferred) and / or 2-4 years’ experience in similar field
Bilingual English & Spanish (Preferred)
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
eCW preferred

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.