Lead Care Manager (Fresno Area)

The Lead Care Manager works in collaboration and continuous partnership with chronically ill or “high-risk” members and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:

· Coordinate with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services

· Engage eligible members

· Oversee provision of ECM services and implementation of the care plan.

· Offer services where the member lives, seeks care, or finds most easily accessible and within the Plan guidelines

· Connect member to other social services and supports the member may need, including transportation

· Advocate on behalf of members with health care professionals

· Use motivational interviewing, trauma-informed care, and harm-reduction approaches

· Coordinate with hospital staff on discharge plans

· Accompany member to office visits, as needed and according to the Plan guidelines

· Monitor treatment adherence (including medication)

· Provide health promotion and self-management training

· Promote timely access to appropriate care

· Increase utilization of preventative care

· Reduce emergency room utilization and hospital readmissions

· Increase comprehension through culturally and linguistically appropriate education

· Create and promote adherence to a care plan, developed in coordination with the member, primary care provider, and family/caregiver(s)

· Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals

· Increase members’ ability for self-management and shared decision-making

· Connecting members to relevant community resources to enhance member health and well-being, increase member satisfaction, and reduce health care costs

· Connect and follow up with members, family/caregiver(s), providers, and community resources via face-to-face, secure email, phone calls, text messages, and other communications

· Serve as the contact point, advocate, and informational resource for members, care team, family/caregiver(s), payers, and community resources

· Work with members to plan and monitor care

· Assess member’s unmet health and social needs

· Develop a care plan with the member, family/caregiver(s), and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)

· Monitor adherence to care plans, evaluate effectiveness, monitor member progress on time, and facilitate changes as needed

· Create ongoing processes for members and family/caregiver(s) to determine and request the level of care coordination support they desire at any given time

· Facilitate member access to appropriate medical and specialty providers

· Educate members and family/caregiver(s) about relevant community resources

· Facilitate and attend meetings between members, family/caregiver(s), care team, payers, and community resources, as needed

· Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals

· Assist with the identification of “high-risk” members (the chronically ill and those with special health care needs), and add these to the member registry (or flag in EHR)

· Attend all Lead Care Manager training courses/webinars and meetings

· Provide feedback for the improvement of the ECM Program

· Offer services where the Member lives, seeks care, or finds most easily accessible and within Medi-Cal Managed Care health plans (MCP) guidelines

· Engage eligible Members

· Arrange transportation

· Call Member to facilitate Member visit with the ECM Lead Care Manager

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below represent the required knowledge, skill, and/or ability. Reasonable accommodations may enable individuals with disabilities to perform essential functions.

· Although this role is remote, there will be times when you will be required to report to our satellite office (or a specified, remote location) to work, to attend meetings, or other training

· Required to have and maintain your own personal vehicle for this role

o You will receive a monthly mileage reimbursement per applicable state/federal laws

· You must have a valid driver’s license, proof of insurance, and a good driving record

· You will visit hospitals and visit patients at their homes, as needed

· Must present proof of Negative TB Test & CPR Certification before hire date

EDUCATION AND/OR EXPERIENCE:

· An associate’s degree, or bachelor's degree in health science or any related health care degree is preferred

· Social Worker, LVN, or experience in case management is a PLUS!

SKILL AND KNOWLEDGE REQUIREMENTS:

· Excellent analytical, problem-solving, and prioritization skills

· Excellent verbal and written communication skills

· High-level of interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and diverse teams that may include employees, customers, and physicians

· Effective computer skills, particularly Microsoft Office, Excel, PowerPoint, Word, etc.

· Work independently to complete assigned tasks

· Team building

· Project Management

· Change Management

· Quality and Process improvement tools

• MUST consistently achieve a minimum daily expectation of 30 schedules/day