1606
Located in Chino, CA
Pay: $20 to $22
Job Full Description
DESCRIPTION
The Care Coordinator/Lead Care Manager works in collaboration and continuous partnership with chronically ill or “high-risk” members and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:
· Coordinate with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services.
· Engage eligible members.
· Oversee provision of ECM services and implementation of the care plan.
· Offer services where the member lives, seeks care, or finds most easily accessible and within the Plan guidelines.
· Connect member to other social services and supports the member may need, including transportation.
· Advocate on behalf of members with health care professionals.
· Use motivational interviewing, trauma-informed care, and harm-reduction approaches.
· Coordinate with hospital staff on discharge plans.
· Accompany member to office visits, as needed and according to the Plan guidelines.
· Monitor treatment adherence (including medication).
· Provide health promotion and self-management training
· Promote timely access to appropriate care
· Increase utilization of preventative care
· Reduce emergency room utilization and hospital readmissions
· Increase comprehension through culturally and linguistically appropriate education
· Create and promote adherence to a care plan, developed in coordination with the member, primary care provider, and family/caregiver(s)
· Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
· Increase members’ ability for self-management and shared decision-making
· Connect members to relevant community resources to enhance member health and well-being, increase member satisfaction, and reduce health care costs.
· Connect and follow up with members, family/caregiver(s), providers, and community resources via face-to-face, secure email, phone calls, text messages, and other communications.
· Serve as the contact point, advocate, and informational resource for members, care team, family/caregiver(s), payers, and community resources
· Work with members to plan and monitor care
· Assess member’s unmet health and social needs
· Develop a care plan with the member, family/caregiver(s), and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
· Monitor adherence to care plans, evaluate effectiveness, monitor member progress on time, and facilitate changes as needed
· Create ongoing processes for members and family/caregiver(s) to determine and request the level of care coordination support they desire at any given time.
· Facilitate member access to appropriate medical and specialty providers
· Educate members and family/caregiver(s) about relevant community resources
· Facilitate and attend meetings between members, family/caregiver(s), care team, payers, and community resources, as needed
· Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
· Assist with the identification of “high-risk” members (the chronically ill and those with special health care needs), and add these to the member registry (or flag in EHR)
· Attend all Lead Care Manager training courses/webinars and meetings
· Provide feedback for the improvement of the ECM Program
· Offer services where the Member lives, seeks care, or finds most easily accessible and within Medi-Cal Managed Care health plans (MCP) guidelines
· Engage eligible Members
· Arrange transportation
· Call Member to facilitate Member visit with the ECM Lead Care Manager
QUALIFICATION REQUIREMENTS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below represent the required knowledge, skill, and/or ability. Reasonable accommodations may enable individuals with disabilities to perform essential functions.
EDUCATION AND/OR EXPERIENCE:
- Associate degree, or Bachelor Degree in Health science or any related health care degree.
- Social Worker, LVN, or experience in case management.
- Must successfully complete and maintain BLS certification
SKILL AND KNOWLEDGE REQUIREMENTS:
- Excellent analytical, problem-solving, and prioritization skills.
- Use statistical and graphic displays.
- Excellent verbal and written communication skills.
- High-level interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and diverse teams that may include employees, customers, and physicians.
- Effective computer skills, particularly Microsoft Office, Excel, PowerPoint, Publisher, Paint, Word, etc.
- Work independently to complete assigned tasks.
- Team building
- Project Management
- Change Management
- Quality and Process improvement tools
- Project Execution
- Must be comfortable to make continuous calls to customers to promote their services
Chino-Upland, CA
2179
12345 Mountain Avenue
Suite Z
Chino, CA 91710
Apply Now Email Us