Care Manager; Hybrid

This position is hybrid
, with some onsite and remote work.

Compensation (Based on experience and qualifications): $63,000 to $78,000

Esperanza Health Centers offers benefits to all its full-time employees:

BCBS Medical PPO Plans | Ameritas Dental |Eye Med Vision | Tuition Reimbursement up to $5,000 per year|10 Paid Holidays and 21 Days of Paid Time Off

The Care Manager is responsible for coordinating screening and providing the intervention of patients with identified complex chronic care needs. The care manager acts as a connector between patient needs and the resources provided by the care management program. This position provides guidance and leadership through the care management program to Esperanza’s care teams and ensures patients receive the best possible care.

• Identifies, tracks and manages care for the highest risk patients using the electronic medical record and other health information platforms.
• Conducts initial care coordination screening eligibility and performs comprehensive risk assessment, either in person or over the phone
• Manages a caseload of 62 patients (commensurate with the Medical Home Network contractual requirement)
• Oversees in the development and implementation of an integrated patient care plan for each of the highest risk patients, either in person or over the phone
• Supports other care managers and primary care teams with the highest risk patients
• Ongoing clinical assessment, monitoring and follow up for high-risk patients
• Utilize standing orders and clinical orders for chronic disease management within scope of clinical practice
• Assesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriate
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Performs medication review, reconciliation and coordination with a licensed professional for medication adjustment
• Oversees transitions of care process and connects patients to post discharge follow up
• Participates in the evaluation of the care management programs, which includes running data reports in the electronic medical record
• Collaborates and participates in the selection, development and maintenance of patient education materials related to healthy lifestyle changes and specific disease management topics.
• Makes hospital visits, as needed, on a case-by-case basis, to perform comprehensive risk assessments and to manage the transition of care between the hospital and the primary care setting.
• Assists in the maintenance of the patients’ health, wellness and prevention of secondary disease complications by providing education, counseling and support.
• Handles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPPA)
• To live up to Esperanza’s mission of being truly involved in the community all staff members are expected to participate in program outreach activities; including but not limited to the Annual Fundraiser, Community Garden(s), and Health Fairs.

• Master’s level behavioral health (e.g., MSW) degree. Must have IL licensure (e.g., LSW, LPC).
• 1-3 years’ experience in disease management or case management.
• Experience working with medically and behaviorally complex patients preferred
• Experience working with children who receive special education preferred
• Ability to speak, read and comprehend English and Spanish
• Displays strong time management and organizational skills in a high intensity work environment.
• Desire to be a self-starter; take initiative.
• Thrives working in a team-based environment
• Knowledge of quality improvement skills preferred
• Experience working in healthcare and/or a primary care setting preferred
• Flexibility to work evenings and/or weekends, if necessary. Must be able to work on-site as needed. Current hybrid schedule.
• Demonstrates problem solving, decision-making, and sound judgment as well as customer service skills.
• Proficient in Electronic Health Record, Microsoft Word and Excel
• Exceptional organizational and interpersonal skills, with attention to detail required; strong oral/written communication skills is a must.

Esperanza Health Centers is an Equal Opportunity Employer (EOE) according to Title 44, Ill. Administrative Code, and Subpart C Section 750.150.