About Job

The Lead Care Manager/LVN 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
Connect 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.

Must successfully complete and maintain BLS certification
Must present proof of Negative TB Test before hire date
Must complete a Live Scan Fingerprint/Background check

EDUCATION AND/OR EXPERIENCE:

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

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
Project Execution
Bi-lingual (Chinese, Mandarin, Spanish) a PLUS!