ECM Lead Care Manager

INTRODUCTION: Central Neighborhood Health Foundation is a Federally Qualified Healthcare Center committed to the Triple Aim as described by the Institute for Healthcare Improvement. Improving the US Health Care System requires simultaneous pursuit of three aims: 1) improving the experience of care, 2) improving the health of populations and 3) reducing per capita costs of health care.

Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an "integrator") that accepts responsibility for all three aims for that population. SUMMARY: The Enhanced Care Management program provides a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need members enrolled in Medi-Cal managed care.

The Lead Care Manager will work with leadership, providers and managed care to determine the needs of high acuity, vulnerable patients. This will include providing basic housing assistance, patient tailored intensive case-management, developing a care/service plan; provide linkages to medical, psychiatric, social, educational and other services as needed.

The Lead Care Manager will also work with the Community Supports Program staff to provide team- based, patient-centered care management for homeless and at-risk of homelessness patients. The goal of the ECM program is to effectively manage high utilizers and homeless patients during their continued care to ensure that their medical and psychosocial needs are met and to minimize the likelihood of preventable hospital admissions and emergency department utilization.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Conducts initial screening, assessments, and reassessments to determine the continued needs of the client. Conducts outreach, enrollment, monthly reporting, and accurate completion of comprehensive risk assessments and care plans. Conducts proper intake steps such as patient data collection, eligibility, program enrollment, care plan development, and assessment of needs.

Works with leadership, providers, and managed care to develop and implement patient focused care plans for clients with chronic conditions. Provides direct care management services to ECM participants in their assigned case load in line with ECM guidelines and recommended services. Conducts regular reviews of patient’s chart to ensure quality services are provided and documented by Lead Care Managers consistently and accurately.

Responds to patient inquiries and refer members to other departments, social services or support services as needed. Works with the Housing Navigation team to ensure enrolled patients, who are experiencing homelessness or are at risk of homelessness, receive proper services. Conducts home visits or site visits for members multiple days a week.

Participates in interdisciplinary case conference meetings with care teams on an ongoing basis. Attends monthly health plan webinars. Ensures completion of comprehensive risk assessment care plans and other health plan requirements. Recruit new ECM members every month by conducting proactive telephonic outreach, member engagement, community networking, and follow-up activities.

Assist in the organization and execution of special events. Complete and submit ECM referral forms to MCP accurately and within established program timelines. Complete and obtain required signatures for patient ROI, PHI, and ECM consent forms and ensure documentation is properly maintained. Address all MCP referrals in a timely manner and conduct appropriate follow-up to support successful member engagement and enrollment.

Conduct telephone outreach to prospective and referred members to explain ECM services, assess interest, answer questions, and facilitate the enrollment process. Maintain accurate and timely records of outreach attempts, member contacts, referrals, enrollments, and other required activities in the EMR and/or designated tracking systems.

Maintain accurate and timely records of outreach attempts, member contacts, referrals, enrollments, and other required activities in the EMR and/or designated tracking systems Performs other related duties as assigned. SUB ROLES: A Lead Care Manager may be assigned to participate in a specialized function within the Enhanced Care Management (ECM) program based on program needs.

Specialized assignments may include the following: Lead Care Manager Trainer: Trains newly hired Lead Care Managers by providing education, guidance, and preparation to support the delivery of compliant, consistent, and high-quality services to ECM members. Updates and maintains training materials to align with current program expectations, workflows, guidelines, and processes.

Provides ongoing support and clarification to Lead Care Managers regarding training content and program requirements as needed following initial training. Organizes and facilitates additional training sessions based on identified staff or program needs. Maintains a limited caseload as assigned. Justice Involved Lead Care Manager: Communicates with referring entities to confirm receipt, eligibility, and acceptance of Justice-Involved members into the ECM program.

Coordinates and schedules warm hand-off meetings with referred members prior to release from incarceration. Participates in scheduled warm hand-off meetings with the prison facility coordinator and referred member to support continuity of care and successful transition into the community. Connects members post-release with the appropriate enrollment provider to assist with necessary changes or updates to Medi-Cal eligibility and managed care enrollment.

Provides transition and care coordination support to newly released members, including assistance with establishing care with their assigned primary care physician. Verifies managed care plan assignment and communicates relevant member information to the ECM Outreach and Enrollment team. Participate in community events special to Justice Involved members Maintains a limited caseload as assigned.

Intake Lead Care Manager: Assesses member needs, identifies barriers to care, and establishes individualized health and care goals in collaboration with the member and care team. Coordinates initial services and linkages to appropriate medical, behavioral health, social, housing, and community-based resources based on identified member needs.

Coordinates initial services and linkages to appropriate medical, behavioral health, social, housing, and community-based resources based on identified member needs. Interim Lead Care Manager: Provides timely and quality care management support to ECM members pending assignment to a permanent Lead Care Manager. Provides care coordination and transition-of-care support to promote continuity of services and maintain member engagement and participation in the ECM program.

Completes required documentation, assessments, care plans, and other program requirements to support ongoing member participation and a smooth transition to the assigned Lead Care Manager. Communicates relevant member needs, services, and care coordination activities to the assigned Lead Care Manager upon transfer of the member.

Clinic Stationed Lead Care Manager: Provides care management and coordination support to ECM members assigned to other Lead Care Managers who are receiving services or visiting the clinic. Meets with and follows up with ECM-enrolled members assigned to other Lead Care Managers to address immediate needs and support continuity of care.

Provides coordination and communication support between ECM members, their assigned Lead Care Manager, and clinic staff as needed. Assists with identifying and addressing member needs that arise during clinic visits and communicates relevant information to the assigned Lead Care Manager. Maintains a caseload as assigned.

QUALIFICATION REQUIREMENTS: To perform this job successfully an individual must be able to perform each essential duty, satisfactorily.

Requirements

listed below are representative of the knowledge, skill and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must have reliable transportation
• Must have a valid driver’s license
• Ability to drive.
• On site attendance Monday – Friday.

EDUCATION

High school diploma required. Bachelor’s degree preferred. Two years of experience in the health care, case management, or related field preferred. Knowledge and experience with Electronic Medical Records. NECESSARY SKILLS: Ability to communicate effectively in both written and verbal form to patients, public, medical staff, and physicians.

Excellent counseling skills and ability to relate to multi-ethnic community and varied income levels. Strong interpersonal skills to establish productive working relationships with multidisciplinary team and support services. Ability to work independently, collaboratively, and possess strong time management skills. Knowledge of the Care Process and ability to apply all steps.

Knowledge of insurance coverage and the insurance eligibility process. Knowledge of the functions and services of local community health agencies and community organizations. Excellent organizational skills and attention to detail. Policy Punctual and regular attendance is an essential responsibility of each employee at CNHF.

Employees are expected to report to work as scheduled, on time and prepared to start working. Employees also are expected to remain at work for their entire work schedule. Late arrival, early departure or other absences from scheduled hours are disruptive and must be avoided. This policy does not apply to absences covered by the Family and Medical Leave Act (FMLA) or leave provided as a reasonable accommodation under the Americans with Disabilities Act (ADA).

These exceptions are described in separate policies. WORK ENVIRONMENT Described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Variations in conditions may occur under certain circumstances. CONFIDENTIALITY Maintains patient, employee, and Foundation confidentiality at all times, discussing patient or employee business only with appropriate parties who have a bona fide need to know; and communicating only the minimum amount of information necessary with respect to protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

AGREEMENT AND ACCEPTANCE I HAVE READ THE ABOVE JOB DESCRIPTION AND FULLY UNDERSTAND THE REQUIREMENTS SET FORTH AND WILL PERFORM ALL DUTIES AND RESPONSIBILITIES TO THE BEST OF MY ABILITY. Monday

• Friday 8:00AM - 4:30PM