About Job

POSITION DESCRIPTION:
Under the direction of the Enhanced Care Management (ECM) program manager, and working as part of an interdisciplinary team, the lead care manager (LCM) is responsible for coordinating person-centered services and comprehensive care management with Medi-Cal recipients who have complex medical and social needs. The LCM engages community members and helps individuals navigate/access community services and resources and adopt healthy behaviors. The ECM program is a community-based care coordination program addressing social determinants of health to bridge service gaps and improve health outcomes for Medi-Cal recipients.

DUTIES AND RESPONSIBILITIES:
Care Management:

Provides comprehensive assessment of identified clients/members.
Develops person-centered care plans based on assessed client needs.
Ensures the implementation of the assessment and care plan.
Provides direct care management services to clients in the Enhanced Care Management program.
May work collaboratively with ECM CHWs, as needed, to assure implementation of care plan.
Forms authentic alliances with clients, uncovering what impedes better health outcomes, and actively works to find solutions.
Engages potential clients in health promotion and self-management.
Engages clients and builds trusting relationships.
Screens for and identifies social and behavioral health needs.
Arranges/assists with linkages to care, including appointments, transportation, etc.
Meets clients where they are in their homes, at health care offices, in the community.
Assists with facilitating clients’ use of technology to conduct virtual visits when needed.
Supports clients in developing health literacy; provides health promotion materials.
Advocates for clients with health care professionals; encourages treatment adherence; collaborates and coordinates with health care providers.
Attends client’s medical visits, as needed.
Works collaboratively with interdisciplinary team of nurses, social workers, and therapists
Participates in case conferences and interdisciplinary team meetings to improve clients’ health outcomes.
Maintains care management records, including assessments, home visits, person- centered care plans, periodic reassessments, and progress notes in the electronic health record.

Outreach and Community Connection:

Builds and uses a community resource network for support with housing, food insecurity, develops and implements creative and resourceful strategies to meet client’s needs.
Conducts a variety of outreach activities to connect with potential clients.

Professional Conduct:

Maintains confidentiality and always treats participants and staff with dignity and respect.
Communicates effectively and respectfully with people from diverse racial, ethnic, and cultural groups and from different backgrounds and lifestyles; demonstrates compassion and sensitivity to their needs.
Develops and maintains positive community relationships with clients, coworkers, supervisors, partners, stakeholders, and the public.
Performs other duties as assigned.

OTHER JOB DETAILS:

This position is both on-site and in the field.
The hours of work are typically Monday-Friday between 7-3:30, however some evening and weekend work may be required.

MINIMUM QUALIFICATIONS:
Required:

Must meet one of the following requirements:
Have a bachelor’s degree in social work, health and human services, or other related discipline.
Understanding of person-centered services and social determinants of health
Ability to develop, implement, and evaluate care plans.
Ability to be persistent, creative and resourceful in locating meaningful community resources and implementing care management plans.
Demonstrates a high level of tolerance and empathy for individuals who present for services with urgent multiple care management and health needs, strong interpersonal skills.
Ability to grow and learn along with the program.
Bilingual/English/Spanish

Preferred:

Experience with chronic illness.
Familiarity with motivational interviewing techniques, de-escalation techniques, and trauma-informed care

Other requirements:

Must pass a TB test before first day of employment.
Must have a valid CA driver’s license, drive a motor vehicle incidental to the performance of the work and be insured.
Lead Care Managers may transport clients and must pass a pre-employment drug screen and comply with periodic testing for drug use and alcohol misuse.
Must be able to work at a computer for full workdays; some routine lifting and reaching requirements.
Must pass a criminal background check and maintain a clean record.

Job Type: Full-time

Pay: $20.00 - $25.00 per hour

Expected hours: 40 per week

Benefits: