Lead Care Manager (Fresno Area)

Blehealth•Fresno, CA

2d•Remote

About The Position

The Lead Care Manager works in collaboration with chronically ill or high-risk members, their families or caregivers, health care providers and staff, and community resources. The role coordinates and oversees Enhanced Care Management (ECM) services, engages eligible members, and supports implementation of member-centered care plans in accordance with Medi-Cal Managed Care health plan guidelines. Services are offered where members live, seek care, or can most easily access them. The Lead Care Manager assesses unmet health and social needs; develops, monitors, and updates care plans; coordinates care transitions, referrals, and provider relationships; and connects members to medical, social, and community resources, including transportation. The role supports members’ self-management and shared decision-making, promotes preventive and timely care, monitors treatment adherence, and advocates for members. Communication and follow-up may occur face-to-face, by secure email, phone, text, or other means. The position also attends required training and meetings and provides feedback to improve the ECM Program. This is a remote role with occasional required reporting to a satellite office or designated remote location for work, meetings, or training. The Lead Care Manager visits hospitals and members’ homes as needed and must maintain a personal vehicle, valid driver’s license, proof of insurance, and a good driving record. A negative TB test and CPR certification must be provided before the hire date. The role has a stated minimum daily expectation of 30 schedules per day.

Requirements

Associate’s degree, or a bachelor’s degree in health science or a related health care field, is preferred.
Must provide proof of a negative TB test and CPR certification before the hire date.
Must maintain a personal vehicle for the role.
Must have a valid driver’s license, proof of insurance, and a good driving record.
Must be able to report occasionally to a satellite office or specified remote location for work, meetings, or training.
Must be able to visit hospitals and members at their homes as needed.
Excellent analytical, problem-solving, and prioritization skills.
Excellent verbal and written communication skills.
Strong interpersonal skills and ability to work collaboratively and tactfully with multidisciplinary and diverse teams, including employees, customers, and physicians.
Effective computer skills, particularly with Microsoft Office, Excel, PowerPoint, and Word.
Ability to work independently and complete assigned tasks.
Team-building skills.
Project management skills.
Change management skills.
Knowledge of quality and process improvement tools.
Ability to consistently achieve a minimum daily expectation of 30 schedules per day.

Nice To Haves

Social Worker, LVN, or case management experience.

Responsibilities

Coordinate with members, families or caregivers, health care providers, and community resources to ensure a seamless experience and avoid duplication of services.
Engage eligible members and oversee the provision of ECM services and implementation of care plans.
Provide services where members live, seek care, or can most easily access them, in accordance with Plan guidelines.
Connect members to social services and supports, including arranging transportation.
Advocate for members with health care professionals and serve as a contact point and informational resource for members, care teams, payers, families or caregivers, and community resources.
Use motivational interviewing, trauma-informed care, and harm-reduction approaches.
Coordinate with hospital staff on discharge plans and accompany members to office visits as needed and according to Plan guidelines.
Monitor treatment and medication adherence, care-plan adherence, member progress, and care-plan effectiveness; facilitate changes as needed.
Provide health promotion and self-management training, culturally and linguistically appropriate education, and support for shared decision-making.
Promote timely access to appropriate care and preventive care, and work to reduce emergency room utilization and hospital readmissions.
Increase continuity of care by managing provider relationships, care transitions, and referrals.
Communicate and follow up with members, families or caregivers, providers, and community resources through in-person visits, secure email, phone calls, text messages, and other communications.
Assess members’ unmet health and social needs and develop care plans with members, families or caregivers, and providers, including emergency plans, health management plans, medical summaries, and ongoing action plans as appropriate.
Create ongoing processes for members and families or caregivers to determine and request their desired level of care coordination support.
Facilitate access to appropriate medical and specialty providers and educate members and families or caregivers about relevant community resources.
Facilitate and attend meetings among members, families or caregivers, care teams, payers, and community resources as needed.
Support primary care and specialty provider co-management through timely communication, inquiry, follow-up, and integration of information about care transitions and referrals into care plans.
Assist in identifying high-risk members and adding them to the member registry or flagging them in the EHR.
Attend all Lead Care Manager training courses, webinars, and meetings.
Provide feedback to improve the ECM Program.
Call members to facilitate visits with the ECM Lead Care Manager.
Consistently meet a minimum daily expectation of 30 schedules per day.