Care Manager

Job Description

Job Description

Job Title: Care Manager

FLSA Status: Non-Exempt

Supervises: None

Reports To: ECM Supervisor

Summary:

The Enhance Care Management (ECM) Care Manager will provide a wide range of case management services for the California Advancing and Innovating Medi-Cal (CalAIM) initiative. Duties include the development of collaborative care management plans with clients which support clients’ needs in the areas of physical health, mental health, substance use disorders, community-based long-term services support, oral health, palliative care, social supports, and social determinants of health. Core ECM activities include but are not limited to, outreach, comprehensive assessment and care management, care coordination, health promotion, comprehensive transitional care, identifying client support needs, and coordination of and referral to community and social services support.

Essential Job Functions:

• Client outreach and engagement, including direct communication with clients such as in-person meetings, mail, email, texts and telephone; community and street-level outreach;
• Complete documentation required for data reporting and outcome tracking;
• Complete a Comprehensive Assessment by researching and analyzing patient records and interviewing patients and/or caregivers;
• Develop a Care Management Plan (CMP) that incorporates client's needs in the areas of physical health, mental health, SUD, community-based Long-Term Services Support, oral health, palliative care, social supports, and Social Determinants of Health;
• Care coordination and organizing client care activities per the CMP and case conferences for care coordination;
• Maintaining an active panel of 50 members;
• Sharing and maintaining information with client's multidisciplinary team and implementing activities per CMP, including Community Supports;
• Support client engagement in support including coordination or medication review and or reconciliation, scheduling appointments, appointment reminders, coordinating transportation, accompany client to critical appointments, identify and address other barriers to client’s engagement in services;
• Ensuring regular contact with the member and their family member(s), guardian, caregiver, and/or authorized support person(s) as part of care coordination;
• Engage and help client participate in and manage their care;
• Coaching members to make lifestyle choices based on healthy behavior - goal is for members to successfully monitor and manage their health;
• Supporting members in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic condition;
• Linkage to resources based on member's needs such as smoking cessation, self-help recovery, etc.;
• Provide transitional care for clients during discharge from hospital or institutional setting including developing a transition care plan (Targeted Care Plan Update), and coordination of care to provide adherence support and referrals to appropriate resources and community supports, as needed;
• Identify supports needed for client;
• Collaboration with Community Supports provider and other community-based organizations to coordinate services;
• Provide appropriate education of the client and/or their family support/authorized support about care instructions for the person served;
• Assist members in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), CalFresh, cash aid, and obtaining required documentation to apply (ID, birth certificate, immigration status, financial records, marriage/divorce records, proof of medical conditions, etc.;
• Develop, establish, and maintain professional and collaborative working relationships with internal and external care team;
• Network with community and stakeholders to remain current on issues and activities as they impact coordination of care for clients;
• Coordination of care with health plans;
• Attend required training to maintain provider certification and current industry knowledge;
• Performs administrative tasks including timely record keeping and data entry;
• Maintains up to date, adequate records and other documentation necessary for the collection of data and statistics pertaining to program outcomes, demographics, and information as required by funders;
• Collaborate as an active member of a team;
• Actively model and communicate the mission and vision and supports a corporate culture of empowerment, team building, and open communication;
• Maintains compliance with all applicable county, state and federal laws and regulations, funder and program requirements;
• Performs other duties as assigned.

Qualifications, Experience, and Essential Skills Requirements:

Education and Experience

• Bachelor’s Degree in the social service field with one (1) year of experience in care coordination/case management preferred OR minimum 4 years of case management and care planning experience in lieu of Bachelor’s Degree.
• Bilingual/Multilingual in English and Spanish, Farsi, Dari, Russian, Arabic, Hmong, Vietnamese, Korean, Chinese, and/or American Sign Language highly preferred
• Experience in outreach and inter-agency referral services preferred
• Experience with Electronic Medical Records (EMR), EPIC preferred
• Knowledge of Sacramento and Yolo County Community Resources strongly preferred
• 1 year of experience with Assessment and Care Planning (SMART format) is strongly preferred
• 2 years of experience with SOAP/encounter note writing is strongly preferred
• 1 year of experience managing 50 or more cases is preferred
• Experience working with the Homeless, Chronically ill, Substance Use Disorders, Serious Mental Illness, and/or Children & Youth is preferred.
• Experience with Enhanced Care Management is preferred
• Knowledge of basic medical terminology
• Strong understanding of HIPAA
• Knowledge of Microsoft Office and Google Suite
• Current BLS certification required

Additional Requirements

• Must have a current and valid California driver’s license and the ability to provide proof personal auto insurance on the vehicle driven during working hours.

Physical Requirements and Work Environment

The work environment is office, clinic, and field-based, administering program education and Care Coordination to Adults, Children, and Youth experiencing homelessness, high utilizers, those with Serious Mental Illness and/or Substance Use Disorders, and recent immigrants. Work environment includes office, clinic, hospitals/facilities, client homes, streets and homeless encampments, and homeless shelters. Employees are to adhere to field visit policies, including, but not limited to being accompanied by a colleague while working with clients in a not public setting. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is frequently required to walk; use hands to finger, handle, or feel. The employee is also required to stand; walk; and reach with hands and arms. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, and the ability to adjust focus. The employee must also possess hearing and speech to communicate in person and over the phone. The noise level in the work environment can range from quiet to moderately loud; the incumbent must be able to focus in an environment with many distractions.

The employee may be in contact with individuals and families in crisis who may be ill, using substances and/or not attentive to personal health. The employee may experience a number of unpleasant sensory demands associated with the client’s use of alcohol and drugs, and the lack of personal care. The employee may also be exposed to bio-hazardous materials (bodily fluids including blood and urine) and hazardous chemicals. The employee must be ready to respond quickly and effectively to many types of situations, including crisis situations and potentially hostile situations.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

*Elica Health Centers is a healthcare facility that adheres to the mandates issued by the California Department of Public Health including the recent orders regarding the COVID-19 vaccine. Medical and religious exemptions will be considered.