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 a 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. Performs other related duties as assigned. SUB ROLES: A Lead Case 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 Case Manager Trainer: Trains newly hired Lead Case 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 Case 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 Case 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. Maintains a limited caseload as assigned.

Intake Lead Case Manager: Completes the initial comprehensive assessment and care plan for newly enrolled ECM members in accordance with program and health plan requirements. 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. Interim Lead Case Manager: Provides timely and quality care management support to ECM members pending assignment to a permanent Lead Case 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 Case Manager. Communicates relevant member needs, services, and care coordination activities to the assigned Lead Case Manager upon transfer of the member.

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

Provides coordination and communication support between ECM members, their assigned Lead Case 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 Case Manager. Maintains a limited 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. KNOWLEDGE, SKILLS, and ABILITIES: 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. 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 Accounting Act of 1996 (HIPAA).

Monday

• Friday 8:00am - 4:30pm