Enhanced Care Management Care Coordinator -Oroville/Butte County

Adobe Care And Wellness LLC•Oroville, CA

18h•$55,000 - $65,000•Onsite

About The Position

Adobe Population Health (APH) is a women-owned health solutions company founded in 2018 with a mission of positively impacting the lives we touch. Headquartered in Phoenix, AZ, with satellite locations across multiple states, APH fosters a culture rooted in inclusivity, human kindness, and high-quality care. Recognized by Inc. 5000 as one of America’s Fastest-Growing Private Companies and honored for a fifth consecutive year as a “Best Place to Work” by the Phoenix Business Journal, APH continues to expand its reach and impact. APH partners with health plans, providers, hospitals, and families to deliver tailored programs including case management, in-home and in-clinic wellness assessments, preventative care, transitional care, and social services. As one of the nation’s few fully integrated healthcare organizations, APH delivers comprehensive, coordinated medical and social support through a wide range of specialized service lines. With continued growth on the horizon, APH is seeking mission-driven individuals who are passionate about improving health outcomes and supporting those in need.

Requirements

Minimum of two (2) years of experience in case management, care coordination, population health, managed care, or related healthcare setting.
Knowledge of California Medi-Cal managed care programs and Enhanced Care Management (ECM) model a plus.
Experience working with high-risk and complex populations, including behavioral health and social determinants of health needs a plus.
Excellent verbal, written, organizational, and interpersonal communication skills.
Proficiency with electronic medical records, care management platforms, and Microsoft Office applications.
Bachelor’s degree in social work, human services, public health, psychology or related field required.
Must be able to physically perform the essential duties of the position which include lifting 30 lbs., transporting materials, stooping, kneeling, crouching, reaching, use of hands, balancing, walking, standing, talking, hearing, and typing.

Nice To Haves

Master’s degree preferred.
Certified Case Manager (CCM) certification preferred.
Bilingual skills preferred based on regional needs.

Responsibilities

Conduct outreach and engagement activities for members identified for ECM services.
Establish trusting relationships with members and their support systems through culturally competent and trauma-informed approaches.
Engage members primarily through in-person visits and utilize telephonic or virtual methods when appropriate.
Serve as the member's primary point of contact throughout ECM enrollment.
Promote member participation in care planning and healthcare decision-making.
Complete comprehensive health and social needs assessments within required regulatory and contractual timelines.
Identify medical, behavioral health, developmental, oral health, long-term services and supports (LTSS), housing, transportation, food insecurity, and other social needs.
Develop individualized, person-centered Care Management Plans in collaboration with members, caregivers, and interdisciplinary care teams.
Regularly review and update care plans based on member progress, changing needs, and clinical recommendations.
Document strengths, goals, risks, barriers, interventions, and outcomes within the care plan.
Coordinate services across physical health, behavioral health, specialty care, oral health, LTSS, community support, and social service systems.
Facilitate communication among providers and multidisciplinary care teams to ensure continuity and integration of care.
Schedule appointments, arrange transportation, provide appointment reminders, and assist members in overcoming barriers to care.
Support medication adherence, medication review, and medication reconciliation activities.
Coordinate care among multiple care management entities to prevent duplication of services.
Ensure member goals and preferences are communicated to all relevant care team members.
Educate members regarding chronic disease management, preventive health, and healthy lifestyle choices.
Encourage members to actively participate in managing their health conditions.
Identify and strengthen family, caregiver, and community support systems.
Assist members in developing skills needed to access healthcare and community resources independently.
Monitor hospital admissions, emergency department visits, skilled nursing facility stays, residential treatment admissions, and other care transitions.
Conduct transition assessments and develop transition plans to support safe movement across care settings.
Coordinate post-discharge follow-up appointments and services.
Complete medication reconciliation activities following transitions of care.
Implement interventions aimed at reducing avoidable hospital admissions and readmissions.
Engage family members, caregivers, authorized representatives, guardians, and support people as appropriate and permitted.
Ensure required consents and authorizations are obtained and maintained.
Educate caregivers regarding care plans, treatment adherence, medication management, and available resources.
Provide copies of care plans and educate members and caregivers on how to request updates or changes.
Identify social drivers of health impacting member outcomes, including housing instability, food insecurity, transportation barriers, employment, legal concerns, and financial hardship.
Coordinate referrals to community-based organizations, social service agencies, and Community Supports providers.
Ensure referrals are completed using a closed-loop process and verify services were received.
Advocate for members to access necessary community and social support services.
Maintain accurate, timely, and complete member records in accordance with Medi-Cal, DHCS, health plan, and organizational requirements.
Document all member contacts, assessments, interventions, referrals, and care coordination activities.
Participate in audits, quality reviews, and compliance monitoring activities.
Ensure all ECM services meet contractual, regulatory, and organizational standards.
Protect member confidentiality and comply with HIPAA and applicable privacy regulations.
Participate in interdisciplinary care team meetings, case conferences, utilization reviews, and provider collaboration meetings.
Attend required ECM, Medi-Cal, compliance, and organizational training programs.
Collaborate with hospitals, primary care providers, behavioral health providers, specialists, LTSS providers, dental providers, and community organizations.
Support organizational quality improvement initiatives and population health goals.
Perform other duties as assigned to support organizational goals.