Lead Care Manager

United Health Centers of the San Joaquin Valley•Fresno, CA

9d•Hybrid

About The Position

We are hiring for a Lead Care Manager to join our growing team. The Lead Care Manager is responsible for serving as the primary point of contact for ECM-enrolled patients, the patient’s family, the Authorized Representative (AR), the caregiver, other authorized support person(s) as appropriate, and the multidisciplinary care team providing care to the patient. The Lead Care Manager also conducts a Comprehensive Assessment and develops a comprehensive Care Management Plan with input from the patient and/or their parent, caregiver, guardian, and multidisciplinary care team, to ensure a whole-person approach is taken in identifying gaps in treatment or gaps in available and needed services.

Requirements

LVN license OR Medical Assistant (MA) certification OR additional education (i.e., Bachelor’s degree) OR several years of progressive experience required (3+ years)
High school Diploma or GED required.
Valid driver's license
3+ years of progressive experience, preferred.
Bilingual (English/Spanish) required.
Able to quickly build and maintain rapport with staff of differing backgrounds; team player
Customer-service oriented
Direct knowledge of the local community.
Strong interest in the community and its people.
Strong computer skills (knowledge of MS Office products and familiarity with medical management software)
Positive professional insight
Strong writing and verbal skills
Flexibility and dependability
Strong foundation of medical terminology
Demonstrated good problem-solving skills; sound judgment
Attention to detail and excellent follow-through on work tasks
Able to handle multiple tasks simultaneously

Responsibilities

Serve as the primary point of contact for the Patient, Patient’s family, Authorized Representative (AR), caregiver, other authorized support person(s) as appropriate, and the multidisciplinary care team providing care to the Patient.
Manages a full patient caseload, with volumes determined by department management according to guidelines set by contracted health plans and other governing bodies.
Conduct a Comprehensive Assessment and under the supervision of the Clinical Consultant develop a comprehensive Care Management Plan with input from the Patient and/or their parent, caregiver, guardian, and multidisciplinary care team.
Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the Patient and non-duplication of services.
Conducts ongoing outreach and engagement, primarily through in-person contact or the patient’s preferred method of communication.
Oversees provision of ECM services and implements the patient’s care plan.
Manages referrals, and coordinates and follows up on needed services and supports.
Offers services where the patient lives, seeks care, or finds most easily accessible.
Organizes patient care activities and maintains at least monthly contact with their providers to ensure coordination, including referrals to specialty mental health.
Advocates on behalf of the patient with health care professionals.
Uses motivational interviewing, trauma-informed care, and harm reduction approaches.
Accompanies patient to office visits as needed.
Monitors care plan adherence.
Provides health promotion and self-management training and identifies support needs for a patient and their family or other caregivers.
Supports the patient in making healthy choices and strengthening skills that allows the patient to better manage their conditions.
Supports the patient and their personal support system during discharge from the hospital and other treatment facilities.
Coordinates with hospital staff on discharge plan.
Attends all required ECM training programs.
Performs other duties that may be assigned.
Attends and actively participates in all meetings (e.g., department meetings, program meetings, employee staff meetings) and other activities as required or assigned.
Attends workshops/seminars as necessary to increase skills and knowledge to provide effective care, treatment, and/or leadership.
Supports the overall needs of the ECM Program by working flexible or extended hours when necessary.
Supports the needs of the ECM Program by traveling to other UHC clinics when necessary.
Demonstrates awareness of, and compliance with, organizational mission and objective of UHC to provide health care access and support services for all patients of the community.
Other work-related duties as assigned by the ECM Manager.
Maintains confidentiality and respect for information regarding patients and other team patients; abides by UHC Rules of Confidentiality and general HIPAA regulations regarding privacy.
Displays a positive, professional and respectful demeanor at all times toward employees, peers, professional contacts, and patients served, maintaining a professional appearance and positive image for the health centers.
Contributes to the team by promoting positive staff interaction, maintains open communication with other programs/departments.