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:

• Health insurance
• Paid sick time

Ability to Commute:

• Brawley, CA 92227 (Required)

Work Location: In person