About Job

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 a reliable means of transportation 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

Must complete a Live Scan Fingerprint/Background check

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

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