Under the direction of ECM Program Manager and the Lead Coordinator, the Lead Care Manager II will outreach and enroll clients in enhanced care management. Will work with leadership, providers, and managed care to determine the needs of high acuity, vulnerable patients and provide basic housing assistance, patient tailored intensive case-management, developing a care/service plan; provide linkages to medical, psychiatric, social, educational and other services as needed. Will also work with the Community Supports Program staff to provide team-based, patient-centered care management for homeless and at-risk of homelessness patients.

Benefits

• Free Medical , Dental & Vision
• 13 Paid Holidays + PTO
• 403 (B) retirement match
• Life Insurance , EAP
• Tuition Reimbursement
• SEIU Union
• Flexible Spending Account
• Continued workforce development & training
• Succession plans & growth within
  
  

Qualifications

Education

• Bachelor’s Preferred
• 2-4 years’ experience in similar field
  
  

Experience

• Working in team-based care and works with others to assist clients in meeting goals.
• Prior experience working with currently and formerly incarcerated individuals
• Willingness to work in various environments, including prison/jail settings
• Offer services where the ECM member lives, seeks care, or finds most easily accessible and within Managed Care Plan’s guidelines.
• Connect enrolled ECM members to other social services and supports he/she/they may need
• Advocate on behalf of enrolled members with health care professionals.
• Use motivational interviewing and trauma informed care practices.
• Work with hospital staff on discharge plans.
• Engage, outreach and enroll eligible ECM members.
• Accompany ECM member to office/clinic/medical visits, as needed and according to MCP guidelines.
• Monitor treatment adherence (including medication)
• Provide health promotion and self‐ management training to enrolled ECM members.
• Arrange transportation when needed for all/any medical appointments.
• Report ECM patient progress, concerns and needs to multi-disciplinary team to improve patient care.
• Work collaboratively with all ECM team & SJCH clinic staff.
• Support the integration of programs into medical care.
• Three years’ experience in social/medical services setting providing targeted care management to multi-ethnic communities with knowledge of and experience working with men, women, children and families and chronic disease management.
• Experience working with chronically homeless patients with HIV, HCV, and/or substance abuse and patients whom are in immediate-risk of homelessness.
  
  

RESPONSIBLITIES

Assessment:

• Conducts intakes and assessments to establish individual patient needs and goals.
• Coordinate all aspects of care, transportation, referral and scheduling.
• Assess Self-management skills of individual patients; Promote and aid patient in establishing self-management skills.
• Link patients to resources in the community, including public benefits and social services.
• LCM II will be expected to carry a caseload 40-50 caseload and conduct case management services via telephonically and in person in Los Angeles, San Bernadino, and Riverside County.
  
  

Documentation:

• Care plan development for patients including goals, objectives and actions to resolve barriers and access to services.
• Maintain client/patient file/record of; appointment, services, follow-ups, and assessments (based on DMH/DHSP/other funders).
• Maintains accurate record keeping, client tracking, data collection and monthly reports.
• Chart case management notes in electronic health records and create alerts for providers, as needed.
• Continued education/training to provide up to date best practice models and policies of working with individuals/families experiencing homelessness, mental illness and/or substance use to provide patient centered/trauma informed care services.
• Maintain contact with patient’s parole office, correctional facilities until patient is released and document as needed, phone calls, conferences.
• Document warm hand off from Correctional Facilities and in person done with the patient after released from jail and/or prison
• Responsible for documenting in Electronic Health Record (EHR) and billing as provided managed care.
  
  

Screening:

• Administers and interprets all screening tools.
  
  

Team:

• Coordinates care provides follow-up and monitors schedules and procedures with patients.
• Work with medical providers to determine health priorities and develop appropriate care management plans.
• Maintains contact with patients, staff, and funders as needed to help reach individual patient wellness goal(s).
• Attend staff meetings, case conferences, team meetings and trainings as needed.
• Crisis management and patient advocacy
• Works in collaboration with partners of the JCOT, Correctional Facilities and attends any/all collaborative meetings.
• Serves as liaison between the professional staff and the community; including
• developing relationships with various stakeholders in the re-entry community.
• Participate/assist as needed in any activities related to the Grant
• Provide support and train LCM and CHW working with the Point of focus: Justice Involved members and History of Incarcerated.
  
  

Organization:

• Coordinates services both internal and external agencies; Correctional Facilities, Managed Care Plans, Parole Offices, and Provider office
• Advocates for patients and agency to community resources and assist with applications as patient after released.
• Liaison between individual/family and community resources.
• Strengthens the individual/family’s ability to access and meet education, health and social/behavioral service needs.
• Assist individuals and families in building the skills and capacity needed to successfully navigate healthcare and social service systems.
  
  

St. John’s Community Health is an Equal Employment Opportunity Employer