BHCC​/ECM Case Manager Round Mountain

Job Details

Level: Experienced

Job Location:

RM Headquarters - Round Mountain, CA 96084

Position Type:
Full Time

Salary Range: $22.00 - $26.00 Hourly

Job Shift: Day

Job Category:
Health Care

Job Title:

BHCC/ECM

Department: ECM

FLSA Status:
Non-Exempt

Reports To:

Director of Case Management

Hours:

4/10 shift, either Mon-Thurs or Tue-Fri

TBD

Location:

Round Mountain

Under general supervision, the Integrated Care Coordinator/ECM provides comprehensive, person-centered care coordination to individuals enrolled in Hill Country Community Clinic’s Enhanced Care Management (ECM) program. This position works collaboratively with patients, medical and behavioral health providers, community partners, health plans, hospitals, specialists, and other members of the patient’s care team to address medical, behavioral health, social, and community support needs. The Integrated Care Coordinator/ECM manages a caseload of complex care patients and provides services in the clinic, by telephone or other approved communication methods, and in community or home-based settings as appropriate.

Responsibilities include completing assessments, developing and maintaining individualized care plans, coordinating services, supporting transitions of care, addressing barriers to treatment, and connecting patients with appropriate healthcare and community resources. This position requires the ability to work effectively with individuals experiencing complex medical, behavioral health, substance use, housing, and social challenges. Services are provided using trauma-informed, harm reduction, motivational interviewing, and person-centered approaches.

The Integrated Care Coordinator/ECM meets patients where they are, promotes patient choice and self-determination, and provides respectful, nonjudgmental, culturally responsive services. The Integrated Care Coordinator/ECM is a billable ECM provider position. Timely, accurate, and complete documentation within the Electronic Health Record (EHR), including appropriate service, diagnosis, time, and billing documentation, is an essential function of this position.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Other duties may be assigned based on program and organizational needs.

• Engage eligible and enrolled ECM patients and develop trusting, person-centered working relationships.
• Complete comprehensive assessments to identify medical, behavioral health, social, housing, transportation, medication, and other care coordination needs.
• Collaborate with patients to develop, implement, and regularly review individualized care plans, goals, interventions, and identified needs.
• Provide ongoing ECM services in accordance with program requirements, patient acuity, individualized care plans, and identified needs.
• Coordinate care with primary care providers, behavioral health providers, specialists, hospitals, pharmacies, social service agencies, Community Supports providers, and other members of the patient’s care team.
• Conduct outreach and follow-up through approved methods, including telephone, electronic communication, clinic visits, community-based contacts, and home visits when appropriate.
• Support patients with scheduling and attending medical, behavioral health, specialty, and other necessary appointments.
• Follow up on missed appointments and assist patients in addressing barriers to care.
• Assist patients with transitions of care following emergency department visits, hospitalizations, skilled nursing stays, or other changes in level of care, including timely follow-up and coordination with the care team.
• Connect patients with appropriate community resources and benefits related to housing, food, transportation, financial assistance, social services, behavioral health, substance use treatment, and other identified needs.
• Provide health promotion, health education, coaching, and support related to self-management goals, medication adherence, treatment plans, preventive care, and overall wellness.
• Utilize motivational interviewing, trauma-informed care, harm reduction principles, and appropriate…