Lead Care Manager

Aria Community Health Center•Porterville, CA

5d•$22 - $23

About The Position

ACHC is a Federally Qualified Health Center and licensed primary care clinic. We provide Family Medicine and Dental Care, with additional specialists in Behavioral Health, Chiropractic, Internal Medicine, Neurology, Pediatrics, Podiatry and Optometry. ACHC Clinics are located across Fresno, Kings and Tulare counties. RESPONSIBILITES Assists ECM Manager and provides care coordination support to the Aria Community Health Center (ACHC) Enhanced Care Management Program to patients residing in Tulare, Fresno and Kings County. This position is pivotal in ensuring all needs of the patient needed to improve health outcomes are coordinated both within the organization as well with outside providers. The needs of the patient may include complex health conditions, mental health diagnosis, shelter concerns, financial instability, extreme poverty, transportation, or food insecurity. The Community Healthcare Worker provides initial outreach to potential eligible patients and works with the eligible patients and care coordinators to meet established goals while using patient centered methodologies. Understanding of motivational interviewing, trauma informed care, and persuasion skills is fundamental to meeting the objectives of the program.

Requirements

Associate degree in Health Sciences or Human Services, or in a closely related field.
1-year experience within a clinic or healthcare setting.
Bilingual English/Spanish
Basic understanding of best practices and/or lifestyle recommendations in common complex conditions including asthma, depression, diabetes, and heart conditions including hypertension.
Basic understanding of various government and non-profit resources including public assistance, rent/utility assistance, food distribution, etc. Experience with Tulare County resources is preferred.
Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.
Communication skills including interpersonal, verbal, and writing. Knowledge and experience in motivational interviewing is preferred.
Organization skills including prioritizing tasks and time management.
Ability to work well under pressure with experience in establishing priorities, meeting deadlines, and adapting quickly to change.
Ability to independently seek out resources as well as work collaboratively in solving barriers to care.
Ability to read, understand and follow oral and written instructions including internal policies and communications as well as applicable local, State, and Federal regulations.
Experience with various software systems including Microsoft Office Suite, Electronic Health Record (EHR) programs, and Payroll programs.
Demonstrates ability to work in a regulatory climate that includes oversight by State and Federal entities, payer contracts, etc.
Possess a genuine respect for others and acceptance of their individual, social, and cultural traits. Experience working with traditionally marginalized populations is preferred.
Able to travel and attend professional meetings, conferences, trainings, and clinic sites.
Valid CA driver license with a clear driving record.
Pass background check for Federally funded programs.

Nice To Haves

Lived experience with a chronic health condition
May substitute one year experience for any of the following Certificates/Licenses: Nursing Assistant, Medical Assistant or Home Health Aide.

Responsibilities

Meet with patients in their homes and/or attend doctor visits to assist the patient with meeting health outcome goals.
May carry a caseload.
Advocate for patient in various settings including internal Multi-Disciplinary Team meetings, Insurance carriers, outside health providers, social workers, resource providers, etc.
Connect patients to needed services that will reduce barriers that impact their health including shelter, transportation, food access, in home care, etc.
Use motivational interviewing and trauma-informed care practices to ensure patients meet the goals established by Clinical Team.
Seek out and engage with patients that meet program eligibility requirements.
Provide health promotion and self-management training to individual patients and their families.
Participate in various meetings, internally and externally.
Submit medical claims needed for program reimbursement including necessary documentation to support claims and actions.
Complete enrollment screening and documentation, and Health Action Plan reports, among other necessary reports.
Verbally present patient case to Multi-Disciplinary Team.