ECM Lead Care Manager

2d4a5356-e068-4295-b443-4d720d34acb5•Santa Fe Springs, CA

1d•$0 - $27•Onsite

About The Position

Central Neighborhood Health Foundation is a Federally Qualified Healthcare Center committed to the Triple Aim: improving the experience of care, improving population health, and reducing per-capita healthcare costs. The Enhanced Care Management (ECM) program takes a whole-person approach to addressing the clinical and non-clinical circumstances of high-need members enrolled in Medi-Cal managed care. The Lead Care Manager works with leadership, providers, and managed care partners to identify the needs of high-acuity, vulnerable patients and provide intensive, patient-tailored case management. The role includes basic housing assistance, care and service plan development, and connections to medical, psychiatric, social, educational, and other services. The Lead Care Manager also works with Community Supports Program staff to provide team-based, patient-centered care management for people experiencing homelessness or at risk of homelessness. The program aims to manage care for high utilizers and homeless patients, meet their medical and psychosocial needs, and reduce preventable hospital admissions and emergency department use. Depending on program needs, a Lead Care Manager may be assigned a specialized function: training newly hired care managers; coordinating ECM transitions for justice-involved members; completing initial assessments and care plans for new members; providing interim care management pending permanent assignment; or supporting members assigned to other care managers while they are at the clinic. Specialized assignments may include maintaining a limited caseload. The position requires on-site attendance Monday through Friday. The stated schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. The employee must maintain patient, employee, and Foundation confidentiality and handle protected health information in accordance with HIPAA.

Requirements

High school diploma required.
Reliable transportation.
Valid driver’s license.
Ability to drive.
Ability to communicate effectively in writing and verbally with patients, the public, medical staff, and physicians.
Counseling skills and ability to relate to a multi-ethnic community and people with varied income levels.
Interpersonal skills to establish productive working relationships with multidisciplinary teams and support services.
Ability to work independently and collaboratively, with strong time-management skills.
Knowledge of the care process and ability to apply its steps.
Knowledge of insurance coverage and the insurance eligibility process.
Knowledge of the functions and services of local community health agencies and organizations.
Strong organizational skills and attention to detail.
Knowledge and experience with Electronic Medical Records.

Nice To Haves

Bachelor’s degree preferred.
Two years of experience in healthcare, case management, or a related field preferred.

Responsibilities

Conduct initial screenings, assessments, and reassessments to determine clients’ ongoing needs.
Conduct outreach and enrollment, complete monthly reporting, and accurately prepare comprehensive risk assessments and care plans.
Complete intake activities, including patient data collection, eligibility review, program enrollment, care plan development, and needs assessment.
Work with leadership, providers, and managed care partners to develop and implement patient-focused care plans for clients with chronic conditions.
Provide direct care management services to assigned ECM participants in accordance with ECM guidelines and recommended services.
Review patient charts regularly to ensure quality services are consistently and accurately provided and documented.
Respond to patient inquiries and refer members to other departments, social services, or support services as appropriate.
Coordinate with the Housing Navigation team to ensure enrolled members experiencing or at risk of homelessness receive appropriate services.
Conduct home or site visits multiple days a week.
Participate in ongoing interdisciplinary case conferences with care teams.
Attend monthly health plan webinars.
Complete comprehensive risk assessment care plans and other health plan requirements.
Perform other related duties as assigned.
When assigned as a Lead Case Manager Trainer, train new Lead Case Managers, maintain and update training materials, provide ongoing guidance, organize additional training sessions as needed, and maintain a limited caseload as assigned.
When assigned to the Justice Involved function, confirm referrals and eligibility with referring entities; coordinate and attend pre-release warm hand-off meetings; connect released members with enrollment providers to address Medi-Cal eligibility and managed care enrollment; support transitions and care coordination, including establishing primary care; verify plan assignment; share relevant information with the ECM Outreach and Enrollment team; and maintain a limited caseload as assigned.
When assigned to the Intake function, complete initial comprehensive assessments and care plans, identify needs and barriers, establish individualized goals with members and the care team, and coordinate initial services and referrals to medical, behavioral health, social, housing, and community resources.
When assigned to the Interim function, provide timely care management and transition-of-care support pending assignment to a permanent Lead Care Manager; complete required documentation, assessments, and care plans; maintain member engagement; and communicate relevant information to the assigned care manager upon transfer.
When assigned to the Clinic Stationed function, support ECM members assigned to other Lead Care Managers while they receive services or visit the clinic; follow up on immediate needs; coordinate communication among members, assigned care managers, and clinic staff; identify needs arising during visits; and maintain a limited caseload as assigned.
Maintain patient, employee, and Foundation confidentiality; discuss patient or employee business only with appropriate parties and communicate only the minimum necessary protected health information.