Lead Care Manager/ Care Coordinator

The Care Coordinator/Lead Care Manager works in collaboration and continuous partnership with chronically ill or “high-risk” members and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:

·       Coordinate with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services.

·       Engage eligible members.

·       Oversee provision of ECM services and implementation of the care plan.

·       Offer services where the member lives, seeks care, or finds most easily accessible and within the Plan guidelines.

·       Connect member to other social services and supports the member may need, including transportation.

·       Advocate on behalf of members with health care professionals.

·       Use motivational interviewing, trauma-informed care, and harm-reduction approaches.

·       Coordinate with hospital staff on discharge plans.

·       Accompany member to office visits, as needed and according to the Plan guidelines.

·       Monitor treatment adherence (including medication).

·       Provide health promotion and self-management training

·       Promote timely access to appropriate care

·       Increase utilization of preventative care

·       Reduce emergency room utilization and hospital readmissions

·       Increase comprehension through culturally and linguistically appropriate education

·       Create and promote adherence to a care plan, developed in coordination with the member, primary care provider, and family/caregiver(s)

·       Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals

·       Increase members’ ability for self-management and shared decision-making

·       Connect members to relevant community resources to enhance member health and well-being, increase member satisfaction, and reduce health care costs.

·       Connect and follow up with members, family/caregiver(s), providers, and community resources via face-to-face, secure email, phone calls, text messages, and other communications.

·       Serve as the contact point, advocate, and informational resource for members, care team, family/caregiver(s), payers, and community resources

·       Work with members to plan and monitor care

·       Assess member’s unmet health and social needs

·       Develop a care plan with the member, family/caregiver(s), and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)

·       Monitor adherence to care plans, evaluate effectiveness, monitor member progress on time, and facilitate changes as needed

·       Create ongoing processes for members and family/caregiver(s) to determine and request the level of care coordination support they desire at any given time.

·       Facilitate member access to appropriate medical and specialty providers

·       Educate members and family/caregiver(s) about relevant community resources

·       Facilitate and attend meetings between members, family/caregiver(s), care team, payers, and community resources, as needed

·       Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals

·       Assist with the identification of “high-risk” members (the chronically ill and those with special health care needs), and add these to the member registry (or flag in EHR)

·       Attend all Lead Care Manager training courses/webinars and meetings

·       Provide feedback for the improvement of the ECM Program

·       Offer services where the Member lives, seeks care, or finds most easily accessible and within Medi-Cal Managed Care health plans (MCP) guidelines

·       Engage eligible Members

·       Arrange transportation

·       Call Member to facilitate Member visit with the ECM Lead Care Manager 

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below represent the required knowledge, skill, and/or ability. Reasonable accommodations may enable individuals with disabilities to perform essential functions.

EDUCATION AND/OR EXPERIENCE:

• Paraprofessional with at least 2 years of experience
• Social Worker, LVN, or experience in case management.
• Must successfully complete and maintain BLS certification

SKILL AND KNOWLEDGE REQUIREMENTS:

• Excellent analytical, problem-solving, and prioritization skills.
• Use statistical and graphic displays.
• Excellent verbal and written communication skills.
• High-level interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and diverse teams that may include employees, customers, and physicians.
• Effective computer skills, particularly Microsoft Office, Excel, PowerPoint, Publisher, Paint, Word, etc.
• Work independently to complete assigned tasks.
• Team building
• Project Management
• Change Management
• Quality and Process improvement tools
• Project Execution