RN - $23.00 to $30.00

The ECM Case Manager will assume responsibilities for community outreach and engagement, determine eligibility, complete enrollment assessments, and perform outreach to potential ECM members to offer an enhanced case management program. This position reports to the Enhanced Care Management (ECM) Program Manager and provides support to ensure engagement, enrollment, and follow‑up on members related to the ECM and other clinical programs where case management is central. Responsibilities Engages patients and offers and/or facilitates care management services where the patient lives, seeks care, or finds them most easily accessible. Conducts comprehensive risk assessments and develops patient‑centered Care Plans that include goals based on the patients’ physical and psychosocial health needs and consider their personal preferences. Oversees effective implementation of Care Plan, ensuring the initial plan is drafted within 30 days from the patient’s enrollment and updated as necessary, but no less than once per quarter thereafter. Educates patients on self‑management skills and/or recruits support from a caregiver/family member to support the accomplishment of the Care Plan. Supports health‑behavior change utilizing motivational interviewing and trauma‑informed care practices. Monitors treatment adherence. Regularly initiates or participates in case conferences with clinical providers. Connects patient to social services, including housing, transportation, etc., as needed to achieve patient’s goals and well‑managed care. Coordinates with hospital staff on discharge plan and with other transitional care as feasible. Accompanies patient to office visits, as needed and according to health plan guidelines. Maintains a regular contact schedule with enrolled patients that includes at least one in‑person encounter per month. Documents care‑management encounters in the Electronic Health Record (EHR) with the appropriate billing codes and internal tracking logs. Performs other duties as assigned. Qualifications Bachelor’s in social services (preferred). 2–3years of experience in a community health or social service setting (required). 2–3years of case‑management/care coordination experience (preferred). Bilingual (bonus). Healthcare: 1year (preferred). Case management: 1year (preferred). Proficiency in Microsoft Office Suite products. Valid driver’s license and willingness to drive to communities where ECM members live (required). Must be able to work in an interdisciplinary team setting. Effective communication and interpersonal skills. Experience with Electronic Health Records (preferred). Ability to independently seek out resources and work collaboratively. Ability to commute: SPA6 and 8 – reliably commute. Willingness to travel: 75% (preferred). Work Location: In person and Remote (Client schedules appointments and meetings). #J-18808-Ljbffr