Care Manager

At ACHC, we are committed to improving the health and well being of our communities. As a Federally Qualified Health Center and licensed primary care clinic, we provide comprehensive medical and dental services, along with specialized care in Chiropractic, Internal Medicine, Neurology, Pediatrics, Psychology, Podiatry, and Optometry. With clinics located across Fresno, Kings, and Tulare counties, our team works together to deliver accessible, high quality care to every patient.

RESPONSIBILITES

Assists Clinic Operations and provides care coordination support to the Aria Community Health Center (ACHC) Patient Centered Medical Home Care Management Program for patients residing in Tulare, Fresno and Kings County. This position is pivotal in ensuring all needs of the patient are identified and coordinated within the organization as well as with outside providers to improve health outcomes. The needs of the patient may include complex health conditions, mental health diagnosis, shelter concerns, financial instability, extreme poverty, transportation, or food insecurity. The Care Manager will be under direct oversight of Clinic Operations for chart review. The Care Manager provides initial outreach to potential eligible patients and works with the eligible patients and care coordinators to meet established goals while using patient centered methodologies. Understanding motivational interviewing, trauma informed care, and persuasion skills is fundamental to meeting the objectives of this position.

ESSENTIAL JOB FUNCTIONS & RESPONSIBILITIES

• Conduct initial and ongoing assessments to identify medical, mental health, substance use, social, housing, and functional needs.
• Carries a caseload of patients consistent with PCMH guidelines.
• Develop individualized, whole person care plans with patient and provider input
• Advocate for patients in various settings including internal multi disciplinary team meetings, insurance carriers, outside health providers, social workers, resource providers, etc.
• Connect patients to needed services that will reduce barriers that impact their health including shelter, transportation, food access, in home care, etc.
• Use motivational interviewing and trauma informed care practices to ensure patients meet the goals established by Clinical Team.
• Engage with patients that meet program eligibility requirements.
• Provide health promotion and self management training to individual patients and their families.
• Conduct regular telephonic outreach and follow up with Patients.
• Complete comprehensive assessments (SDOH).
• Complete enrollment screening and documentation, Health Action Plan reports, and other necessary reports.
• Obtain required Care Management enrollment consents.
• Function as a patient advocate.
• Meet care management documentation expectations.
• Promote wellness and prevention.
• Verbally present patient case to multi disciplinary team.
• Distribute health promotion materials.
• Responsible for accurate and timely documentation which includes but is not limited to program enrollment, assessment, updated activity/progress notes, resource access applications, releases of information, and other forms necessary to document services.
• Support other Care Managers with delegated tasks.
• Ensures the privacy and security of Protected Health Information (PHI) as outlined in ACHC policies and procedures.
• Other duties as assigned, including but not limited to verification of insurance eligibilities and submission of treatment authorizations.