Lead Care Manager- Enhanced Care Management Program

Job Title: Lead Care Manager- Enhanced Care Management Program

Location: Be Finally Free, Bakersfield, CA. 93301

Reporting To: ECM/CS Director

The Enhanced Care Management (ECM) Case Manager addresses the clinical and non-clinical needs of high-need members through systematic coordination of services and comprehensive, community-based, interdisciplinary, high-touch, and person-centered care management. The ECM care managers work with youth and adult community members who have chronic health conditions, are experiencing or are at-risk of homelessness, struggling with substance use, have behavioral or mental health needs, and/or are transitioning from incarceration. Using excellent communication skills, care managers will provide services and coordination to members to ensure continuity of care across health and social service programs, as well as community-based and long-term support service programs. This position requires strong interpersonal and organizational skills to build rapport with members and to coordinate referrals and care amongst various healthcare providers and community services. The ECM case manager also collaborates with the member’s interdisciplinary team to support them. The care manager engages members and their support systems to define priorities that align with the member’s desired needs and goals.

Essential Duties and Functions:

• Teach and assist members to better manage their chronic diseases using realistic and SMART (specific, measurable, attainable, realistic, and time-bound) goals
• Utilize a person-centered approach in designing care plans led by members' own goals and needs.
• Provide as-needed support to members regarding medical needs to assist in the understanding of disease knowledge, medication compliance, specialty services recommended by the provider, and/or any other medical needs the members may require assistance in understanding
• Assist members and their families in problem-solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance)
• Conducts home visits or meets clients in community-based locations to engage and assist with ECM-related services
• Use a flexible approach with a diverse population
• Attend both mandatory in-service trainings and related conferences to support a fundamental and expanded knowledge of Enhanced Care Management services and strategies to meet quality outcomes for ECM goals.
• Advocate on behalf of the members as needed with the medical, behavioral, substance use, and treatment teams.
• May assume advocate role on the member’s behalf to ensure approval of the necessary supplies/services for the patient in a timely fashion
• Manage own caseload while providing monthly care to all members as needed and reducing barriers to care.
• Provided community-based resources to members
• Completing Comprehensive Assessment
• Promoting health and working with members regarding the provider’s health plan
• Take the lead with an interdisciplinary team (ICT) to complete the needed program requirements.
• Complete documentation of encounters/notes for all care coordination services on the EHR
• Utilizes a computer for detailed data entry in multiple applications, including Microsoft Office and Excel
• Follow up with members’ missed appointments and referrals
• Follow-up with hospital/Urgent care discharges
• Collaborate with ECM providers, including physicians and nurse practitioners.
• Using motivational interviewing skills to engage and help members and their support systems.
• Scheduling, appointment reminders, and coordination of transportation
• Assist with ECM Outreach: contacting ECM-eligible members to initiate services
• Complete the required interagency and other necessary paperwork
• Maintain confidentiality in accordance with clinic policies and HIPAA regulations
• Cooperatively follow the required office procedures.
• Work in cooperation with co-workers and supervisory staff

Other Requirements:

• Ability to travel within Kern County as needed.
• Valid driver's license and access to a reliable vehicle.

*Lived Experience Preferred

Application Process:

Interested candidates should submit a resume and cover letter to James Tompkins at jamest@befinallyfree.org.

Job Type: Full-time

Pay: $20.00 - $23.00 per hour

Benefits:

• 403(b)
• Dental insurance
• Health insurance
• Life insurance
• Paid sick time
• Paid time off
• Vision insurance

Work Location: In person