Enhanced Care Management - Lead Care Manager - Carson

Counseling and Research Associates•Carson, CA

6d•Hybrid

About The Position

The ECM Lead Care Manager serves as the primary point of contact for participants in the ECM program. The ECM Lead Care Manager develops a comprehensive Care Management Plan with input from a multidisciplinary care team, as well as the member, and coordinates all care needs and services, such as physical health, behavioral health, social needs, and long-term services and supports.

Requirements

A Bachelor's degree related to the fields of psychology, social work or other majors defined by the Department of Mental Health as a related degree)- OR- an AA degree in Human Services, Social Work, or Psychology plus two years' experience working with high risk populations.
Two years case management experience, demonstrating familiarity and comfort level in working with ECM populations.
Valid California Driver's License, good driving record, and must be able to drive to fulfill the duties of the position.

Responsibilities

Schedules appointments and provides intakes per department guidelines and productivity goals and ensures appropriate intake steps are followed, including eligibility, assessment of needs, collecting patient data, enrolling in programs, developing care plan, and other steps as required by department guidelines. Able to follow-up on referrals and complete outreach activities within established timeframes.
Conducts initial assessments and periodic reassessments of client's needs. Facilitates enrollment of patients in specialty care and services.
Provides direct in-person services for participants in their assigned case load. Performs services "in the field" with the purpose of maximizing high-touch services. Collaborates with the member to help them build upon resiliencies; healthy lifestyle choices; self-care mgt; strengthen skills to enable the member to identify and access resources to assist them in managing their own conditions and prevent other chronic condition. Schedules weekly and monthly phone calls with members.
Able to develop patient-focused, individual plans of care that are person-centered, and strength based in partnership with the member and other providers. Is able to communicate and coordinate with various entities associated with the members care team and leads the provision and coordination of services.
Demonstrates an understanding of trauma-informed care and strength based and culturally competent services. Demonstrates an understanding of "core" medical/MH conditions and challenges faced by the ECM target populations and knowledge of Social Determinants of health (SDOH). Demonstrates the ability to integrate Motivational Interviewing throughout all interactions with the member.
Develops resources and community networks and services that can meet the members identified needs.
Able to work in close collaboration with health plan partners and medical staff to develop, implement, and coordinate care plans for clients with chronic conditions such as diabetes, asthma, behavioral health conditions.
Provides basic and intensive individual support, based on client need. Support may include providing interventions, providing internal and community services referrals, and more intensive support which may include a home visit.
Facilitates care transitions between providers, partners, referral sources and specialty care providers. Demonstrates the ability to help the member transition safely and easily between different levels of care and delivery systems and to execute needed care coordination triggered by care transitions.
Educates patients about health maintenance and disease prevention.
Tracks, monitors, and actively manages assigned patient cases to ensure coordination of care, retention of patient, and ensuring a high level of utilization is maintained. Monitors and reports changes in patient symptoms or behaviors.
Completes all required documentation accurately, thoroughly and in a timely manner, in accordance with department standards. Assists in preparing reports as required.
Travels independently to various environments (buildings with stairs, various communities, schools, etc.).
Attends all staff meetings, in-service training and conferences as required and scheduled.
Maintains strict confidentiality over all records and information relative to the client.
Ensures the safety of clients by providing direct crisis intervention and therapeutic guidance.
Meets regularly with supervisor to review cases and performs other duties as assigned by the supervisor.