ECM Lead Care Manager - Fresno Administration

21890 Colorado AvenueP.O. Box 737 PH 559 693 -2462 San Joaquin CA 93660 FAX 559 693 -3005 JOB DESCRIPTION POSITION LEAD CARE MANAGER REPORTS TO DIRECTOR OF PATIENT SERVICES POSITIONS SUPERVISED NONE CLASS REGULAR CAT FULL -TIME NON -EXEMPT BASIC FUNCTIONS The Enhance Care Management ECM Lead Care Manager CM will provide a wide range of case management services for the California Advancing and Innovating Medi -Cal CalAIM initiative. This position reports to the Director of Health Education. Duties include the development of collaborative care management plans with clients which suppor t clients needs in the areas of physical health mental health substance use disorders community -based long-term services support oral health palliative care social supports and social determinants of health. Core ECM activities include but are not limited to outreach comprehensive assessment and care management care coordination health promotion comprehensive transitional care identifying client support needs and coordination of and referral to community and social services support. DUTIES A ND RESPONSIBILITIES 1. Client outreach and engagement including direct communication with client such as in person meetings mail email texts and telephone community and street -level outreach 2. Maintains compliance with all applicable county state and fed eral laws and regulations funder and program requirements 3. Maintains compliance with all Medi -Cal requirements 4. Complete client assigned service bundles within the MCP and CalAIMs allocated time frame and maintain up to date documentation for services provi ded to respective clients compliant with Knox -Keene HIPAA and DMHC standards 5. Carries a caseload of 30 -50 active cases. Typical client engagementcontact requirement is 1xmonth based on level of acuity for a period of 6 -12 months 6. Completeupdate inbound reporting file and outreach log within 24hrs of service rendered 7. Complete a Comprehensive Intake assessment on each patient 8. Develop a Care Management Plan CMP that incorporates members needs in the areas of physical health mental health SUD communit y-based Long Term Services Support oral health palliative care social supports and Social Determinants of Health 9. Care coordination and organizing patient care activities per the CMP and case conferences for care coordination 10. Sharing and maintaining inf ormation with clients multidisciplinary team and implementing activities per CMP including Community Supports 11. Support client engagement in treatment including coordination or medication review and or reconciliation scheduling appointments appointment r eminders coordinating transportation accompany client to critical appointments identify and address other barriers to clients engagement in treatment 12. Ensuring regular contact with the member and their family members guardian caregiver andor autho rized support persons as part of care coordination 13. Engage and help client participate in and manage their care 14. Coaching members to make lifestyle choices based on healthy behavior - goal is for members to successfully monitor and manage their health 15. Supp orting members in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic condition Job Description Lead Care Manager Page 2 16. Linkage to resources based on members needs such as smoking cessation self -help recovery etc. 17. Provide transitio nal care for clients during discharge from hospital or institutional setting including developing a transition care plan and coordination of care to provide adherence support and referrals to appropriate resources and community supports as needed 18. Identify supports needed for client 19. Collaboration with Community Supports provider to coordinate services 20. Provide appropriate education of the member andor their family supportauthorized support about care instructions for the member 21. Assist members in accessing additional benefits and related documentation such as Social Security Insurance SSI CalFresh cash aid and obtaining required documentation to apply ID birth certificate immigration status financial records marriagedivorce records proof of medi cal conditions etc. 22. Develop establish and maintain professional and collaborative working relationships with internal and external care team 23. Network with community and stakeholders to remain current on issues and activities as they impact coordination of care for clients. 24. Coordination of care with health plans 25. Attend required training to maintain provider certification and current industry knowledge 26. Performs administrative tasks including timely record keeping and data entry 27. Maintains up to date within 24 hours of service delivery adequate records and other documentation necessary for the collection of data and statistics pertaining to program outcomes demographics and information as required by funders 28. Collaborate as an active member of a team 29. Active ly models and communicates the mission and vision and supports a corporate culture of empowerment team building and open communication 30. Assist o ther departments as needed maintaining confidentiality of VHTs business. 31. Observe and practice all VHT Patien t Experience Service Standards as outlined in World Class Practices My Commitment to Care which I have read and signed. 32. Practice CICARE techniques including phone etiquette guidelines when interacting with patients their families visitors or inte rnal customers. 33. Respect privacy and dignity of our patients family members visitors and co -workers. 34. Maintain professionalism in the presence of patients their families visitors and co -workers. 35. Act as a role model verbally and behaviorally demonstrati ng skill enthusiasm positive problem solving commitment and loyalty to the profession and the organization. 36. Follow applicable regulations and standards Joint Commission OSHA HIPAA and CLIA. 37. Perform other duties as assigned by supervisor. MINIMUM QUALIFICATIONS 1. Bachelors Degree from an accredited college or university 1-2 years related experience andor training or equivalent combination of education and experience 2. Minimum 1 -2 years of work experience preferably providing enhancedintensive ca se management services with Medi -Cal physical behavioral health and high -risk populations 3. Familiarity and experience documenting medical necessity meeting MedicareMedi -Cal standards 4. Equivalent combination of education training and work experience to demonstrate ability to perform the above tasks 5. Certificate of Health Education Specialist CHES preferred 6. Bi-lingual English and Spanish f luent both in written and oral communication 7. Current Basic Life Support Card MINIMUM KNOWLEDGE AND ABILITY 1. Ability to communicate effectively and work with an interdisciplinary team 2. Highly motivated and creative individual with lots of energy 3. Strong customer ser vice skills preferably within the service industry and maintain an effective and positive working rel ationship with staff and patients Job Description Lead Care Manager Page 3 4. Strong clinical skills in bio -psychosocial assessment comprehensive case management and supportive services 5. Excellent oral and written communication skills - be able to provide information in a clear and concise manner good interpersonal skills and show professionalism at all times 6. Knowledge of substance use mental health assessments intervention and coordinated care strategies 7. Be self -motivated independent and have the ability to prioritize work and meet deadlines 8. Must be computer literate and have working knowledge of MS Office Suite e.g. Word Excel etc. 9. Modern office practices and procedures including email 10. Must have excellent attention to detail 11. Must have own reliable transportation available for daily us e valid California Drivers License and current proof of automobile insurance coverage as required by the State of California 12. Demonstrated ability to provide world -class patient experience using CICARE principles and practices. Ability to be proactive and to go above and beyond the call of duty take initiative to provide a world class patient experience in all encounters via email phone or in person TYPICAL WORKING CONDITIONS The office setting is a normal work environment. Occasionally work during e arly morning evening or weekend. May be subjected to temperature variances in the office and out in the field. Local travel required TYPICAL PHYSICAL DEMANDS Requires sitting standing or walking for up to eight hours a day. Some bending stretchi ng or reaching may be necessary. Lifting up to 60 pounds may be required on occasion. Vision must be correctable to 2020 and hearing must be in the normal range for telephone contact. WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job the employee may come in contact with hazardous equipment such as liquid nitrogen cleaning agents and sharps. The noise level in the work environment is usually moderate but may become excessively loud with the increased patient flow during a busy clinic day. I the employee understand the responsibilities and standards of my position as listed above and I agree to fulfill them to the best of my ability. I understand I am an at -will employee and can be terminated at any time with or withou t cause. I also understand the Valley Health Team Inc. will not be responsible in any manner for terminations which are due to defunding of Federal or State Contracts. I also agree that the VHT Board of Directors have the right to modify the Personnel P olicies which govern my employment at any time. This organization is an Equal Opportunity Employer. It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race age color sex religion n ational origin or other protected classification. __ _____ Employees Signature Date