Lead Care Manager (Fresno Area)

The 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
• Connecting 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

• Although this role is remote, there will be times when you will be required to report to our satellite office (or a specified, remote location) to work, to attend meetings, or other training
• Required to have and maintain your own personal vehicle for this role
• You will receive a monthly mileage reimbursement per applicable state/federal laws
• You must have a valid driver's license, proof of insurance, and a good driving record
• You will visit hospitals and visit patients at their homes, as needed
• Must present proof of Negative TB Test & CPR Certification before hire date

EDUCATION AND/OR EXPERIENCE

• An associate's degree, or bachelor's degree in health science or any related health care degree is preferred
• Social Worker, LVN, or experience in case management is a PLUS!

SKILL AND KNOWLEDGE REQUIREMENTS

• Excellent analytical, problem-solving, and prioritization skills
• Excellent verbal and written communication skills
• High-level of 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, Word, etc.
• Work independently to complete assigned tasks
• Team building
• Project Management
• Change Management
• Quality and Process improvement tools
• MUST consistently achieve a minimum daily expectation of 30 schedules/day