Lead Care Manager

Eisner Health Open•Los Angeles, CA

2d•Hybrid

About The Position

This position is hybrid status, which requires a combination of remote and on-site work. Will be assigned an estimated 2-3 days onsite per week. The Lead Care Manager serves as the primary contact to patients enrolled in the Enhanced Care Management (ECM) Program and plays a central role connecting the care team members with the patient and with each other for optimal communication about the patient’s Care Plan. The ultimately goal of ECM is to effectively manage the patients over the continuum of care to ensure that their medical and psychosocial needs are met for a well-managed health condition and to minimize the likelihood of preventable hospital and emergency department utilization.

Requirements

Bachelor Degree required
Two years of experience in community health or social service setting required
Case management / care coordination experience
English and Spanish fluency required
Proficiency in Microsoft Office Suite products
Ability to travel locally to Eisner Health sites and communities where ECM patients live.
Must be able to work in interdisciplinary team setting
Effective communication and interpersonal skills
Ability to independently seek out resources and work collaboratively

Nice To Haves

Experience with Electronic Health Records preferred

Responsibilities

Engages eligible ECM patients and offers and/or facilitates care management services where the patient lives, seeks care, or finds most easily accessible.
Conducts comprehensive risk assessments and develops patient-centered Care Plans that includes goals based on the patients’ physical and psychosocial health needs, and considers their personal preferences.
Oversees effective implementation of Care Plan, ensuring initial plan is drafted with 60 days from the patient’s enrollment and that it is updated as necessary, but no less than one per quarter, thereafter.
Educates patients on self-management skills and/or recruits support from a caregiver/family member to support the accomplishment of the Care Plan.
Supports health behavior change utilizing motivational interviewing and trauma informed care practices.
Monitors treatment adherence.
Regularly initiates or participates in case conferences with providers and/or ECM Clinical Consultants.
Connects patient to social services, including housing, transportation, etc., as needed to achieve patient’s goals and well-managed care
Coordinates with hospital staff on discharge plan and with other transitional care as feasible.
Accompanies patient to office visits, as needed and according to health plan guidelines.
Maintains a regular contact schedule with enrolled patients that includes at least one in-person encounter per month.
Document care management encounters in the Electronic Health Record (EHR) with the appropriate billing codes.
Documents outreach attempts in ECM tracking spreadsheet and i2i tracking group.
Support the completion of ECM monthly reports for each Health Plan.
Perform other duties as assigned.