Enhanced Care Management - Lead Care Manager

The ECM Lead Care Manager serves as the primary point of contact for participants in the ECM program. The ECM Lead Care Manager develops a comprehensive Care Management Plan with input from a multidisciplinary care team, as well as the member, and coordinates all care needs and services, such as physical health, behavioral health, social needs, and long- term services and supports.

The ECM Lead Care Manager reports to the ECM Director.

DUTIES:

1.
INTAKE
:
Schedules appointments and provides intakes per department guidelines and
productivity goals and ensures appropriate intake steps are followed, including eligibility,
assessment of needs, collecting patient data, enrolling in programs, developing care plan,
and other steps as required by department guidelines. Able to follow-up on referrals and
complete outreach activities within established time frames.

2.
ASSESSMENTS
:
Conducts initial assessments and periodic reassessments of client's
needs. Facilitates enrollment of patients in specialty care and services.

3.
DIRECT SERVICES
:
Provides direct in-person services for participants in their assigned
case load. Performs services "in the field" with the purpose of maximizing high- touch
services. Collaborates with the member to help them build upon resiliencies; healthy
lifestyle choices; self-care mgt; strengthen skills to enable the member to identify and
access resources to assist them in managing their own conditions and prevent other
chronic condition. Schedules weekly and monthly phone calls with members.

4.
CARE PLANNING
:
Able to develop patient-focused, individual plans of care that are
person-centered, and strength based in partnership with the member and other
providers. Is able to communicate and coordinate with various entities associated with
the members care team and leads the provision and coordination of services.

5.
KNOWLEDGE
:
Demonstrates an understanding of trauma-informed care and strength
based and culturally competent services. Demonstrates an understanding of "core"
medical/MH conditions and challenges faced by the ECM target populations and
knowledge of Social Determinants of health (SDOH). Demonstrates the ability to
integrate Motivational Interviewing throughout all interactions with the member.

6.
RESOURCES
:
Develops resources and community networks and services that can meet
the members identified needs.

7.
COLLABORATION
:
Able to work in close collaboration with health plan partners and
medical staff to develop, implement, and coordinate care plans for clients with chronic
conditions such as diabetes, asthma, behavioral health conditions.

8.
SUPPORT
:
Provides basic and intensive individual support, based on client need. Support
may include providing interventions, providing internal and community services referrals,
and more intensive support which may include a home visit.

9.
TRANSITIONS
:
Facilitates care transitions between providers, partners, referral sources
and specialty care providers. Demonstrates the ability to help the member transition
safely and easily between different levels of care and delivery systems and to execute
needed care coordination triggered by care transitions.

10.
EDUCATION
:
Educates patients about health maintenance and disease prevention.

11.
MONITORING
:
Tracks, monitors, and actively manages assigned patient cases to ensure
coordination of care, retention of patient, and ensuring a high level of utilization is
maintained. Monitors and reports changes in patient symptoms or behaviors.

12.
DOCUMENTATION
:
Completes all required documentation accurately, thoroughly and in
a timely manner, in accordance with department standards. Assists in preparing reports
as required.

13.
TRAVEL
:
Travels independently to various environments…

Enhanced Care Management - Lead Care Manager - Carson