Lead 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 ECM Manager and provides care coordination support to the Aria Community Health Center (ACHC) Enhanced Care Management Program to patients residing in Tulare, Fresno and Kings County. This position is pivotal in ensuring all needs of the patient needed to improve health outcomes are coordinated both within the organization as well with outside providers. The needs of the patient may include complex health conditions, mental health diagnosis, shelter concerns, financial instability, extreme poverty, transportation, or food insecurity. The Lead 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 of motivational interviewing, trauma informed care, and persuasion skills is fundamental to meeting the objectives of the program.

ESSENTIAL JOB FUNCTIONS & RESPONSIBILITIES

• Advocate for patient in various settings including internal Multi-Disciplinary Team meetings, Insurance carriers, outside health providers, social workers, resource providers, etc.
• 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 ECM Patients.
• 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 any other forms necessary to document services.
• Support other ECM Care Team patients with delegated tasks.
• Ensure the privacy and security of Protected Health Information (PHI) as outlined in the policies and procedures relating to HIPPA compliance.
• Participate in community outreach activities to bring visibility to the program and services as needed.
• Educate patients about ECM services and assist them with enrollment in services.
• Serve as the primary liaison between the patient and any services they may need.
• Support individuals and their families as they navigate the health care system and support the development of self-care and health care management techniques.
• Establish trusting relationships with patients and their families while providing general support and encouragement.
• Provide ongoing follow-up, basic motivational interviewing, and goal setting with patient/family to ensure patient meets the goals established by clinical team.
• Meet patients in clinic, facility, or at home to help identify social determinants of health impacting patient's health and general well-being.
• Collaborate with the full care team to create individualized, linguistically, and culturally appropriate care plans for every enrolled patient.
• Assist patient in accessing health-related services and community resources, such as accompaniment to specialist appointments and assistance with enrollment forms that will reduce barriers that impact their health.
• Facilitate communication between all parties (patients, families, colleagues, and community-based organizations) as needed.
• Help patients set personal health related goals and attend appointments.
• Help patients connect with transportation resources and provide appointment reminders in special circumstances.
• Work closely with medical providers to help ensure that patients have a comprehensive and coordinated care plan.
• Manage assigned caseload of patients.
• Other duties as assigned, including, but not limited to verification of insurance eligibilities, submission of treatment authorizations, and other duties as assigned.

Education:

• Preferred: Associate degree in Health Sciences or Human Services, or in a closely related field.

Experience:

• 1-year experience within a clinic or healthcare setting.
• Required: Bilingual English/Spanish
• Preferred: Lived experience with a chronic health condition

May substitute one year experience for any of the following Certificates/Licenses: Nursing Assistant, Medical Assistant or Home Health Aide.

Skills / Ability:

• Basic understanding of best practices and/or lifestyle recommendations in common complex conditions including asthma, depression, diabetes, and heart conditions including hypertension.
• Basic understanding of various government and non-profit resources including public assistance, rent/utility assistance, food distribution, etc. Experience with County resources is preferred.
• Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.
• Exercise appropriate judgment and decision making.
• Communication skills including interpersonal, verbal, and writing. Knowledge and experience in motivational interviewing is preferred.
• Able to sufficiently engage patients and providers on the phone and in person.
• Organization skills including prioritizing tasks and time management.
• Works collaboratively with others and a willingness to participate fully in the team process.
• Ability to work well under pressure with experience in establishing priorities, meeting deadlines, and adapting quickly to change.
• Ability to independently seek out resources as well as work collaboratively in solving barriers to care.
• Ability to read, understand and follow oral and written instructions including internal policies and communications as well as applicable local, State, and Federal regulations.
• Proficient with various software systems including Microsoft Office Suite, Electronic Health Record (EHR) programs, and Payroll programs.
• Demonstrate ability to work in a regulatory climate that includes oversight by State and Federal entities, payer contracts, etc.
• Possess a genuine respect for others and acceptance of their individual, social, and cultural traits. Experience working with traditionally marginalized populations is preferred.
• Requires the ability to drive to patient residences or healthcare facilities based on scheduling and care needs.
• Able to travel and attend professional meetings, conferences, trainings, and clinic sites.

Other Requirements:

• Required: Valid driver's license and proof of car insurance are required.
• Required: Pass background check for Federally funded programs.

General Expectations:

• Committed to the mission of Aria Community Health Center.
• Conduct yourself in a professional manner and consistently demonstrate and promote the values of respect, honesty, and dignity for the patient, families, and all patients of the health care team.
• Committed to the constant pursuit of excellence and teamwork in improving the care of the patient and families in the community.
• Punctual for scheduled work and uses time appropriately.
• Perform duties in a conscientious, cooperative manner.
• Perform required work in a timely fashion with minimal errors.
• Maintain confidentiality and protect the program by abiding by laws and principles related to confidentiality; keep information concerning Program Operations, patients and employees confidential.

Physical/Cognitive Requirements:

• Hearing: Adequate to perform job duties in person and over the telephone.
• Speaking: Must be able to communicate clearly in person and over the telephone.
• Vision: Visual acuity adequate to perform job duties, including reading information from printed sources and computer screens.
• Cognitive: Aptitude to complete tasks, including abilities such as learning, remembering, focusing, categorizing, and integrating information for decision making, problem-solving, and comprehending.
• Other: Requires occasional lifting and carrying items weighing up to 20 pounds unassisted. Requires frequent bending, reaching, and repetitive hand movements (specifically keyboarding and writing), standing, walking, squatting and sitting, with some lifting, pushing and pulling exerted regularly throughout a regular work shift.

NOTE: The essential job functions for this position include but may not be limited to those listed in this job description. Employees hired for this position must be able to perform the essential functions of this job without imposing significant risk of substantial harm to the health or safety of themselves or others.

BENEFITS

• 403(B) matching
• Medical Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• Paid Holidays
• Vacation Pay
• Sick Pay

Aria Community Health Center participates in E-Verify.

Aria Community Health Center is an equal opportunity employer and does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.