POSITION SUMMARY:

Under the direction of the Program Director, the Lead Care Manager (LCM) provides direct service, as well as coordinates care management and functions as a part of a "Care Team" for the Enhanced Care Management Program (ECM). The LCM oversees specific cases, coordinates health care benefits, provides education and facilitates client access to care in a timely and cost-effective manner. The LCM collaborates and communicates with clients, caregivers/family support persons, and other providers to promote wellness, recovery, independence, resilience, and empowerment, while ensuring access to appropriate services and maximizing client benefit. The LCM also serves as an advocate for clients, an active client of the interdisciplinary team, a liaison with other programs and external health and social service providers in the community.

PROGRAM DESCRIPTION:

Enhanced Care Management (ECM) is a Medi-Cal benefit for individuals with complex medical and social circumstances that addresses their clinical and non-clinical needs through intensive coordination of health and health-related services. 

GENERAL REQUIREMENTS:

• Education/Experience

1. Bachelor’s degree in related field or high school diploma/GED with 2 years of relevant experience.
2. Ability to work flexible hours, including occasional evening shifts.
3. Multilingual capabilities preferred, but not required 
4. Prior experience as a Community Health Worker, Peer Support Specialist, or Medical Assistant preferred. 

Licensure, Registration, Certification

1. Valid CA driver’s license and proof of automobile insurance.
2. Completion of CPR/First Aid/ProACT certification within the first thirty (30) days of employment.

JOB DUTIES & RESPONSIBILITIES:

• Assess client needs in the areas of physical health; mental health; SUD; oral health; trauma- informed care; social supports; housing; vocational/employment; wellness; and referral and linkage to community-based services and supports.
• Oversees the development and implementation of the Individual Care Plan/Health Action Plan
• Offer services where the client lives, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services.
• Connect clients to other social services and supports that are needed (e.g., community support group).
• With permission, coordinate/advocate on behalf of client with health care professionals (e.g., PCP)
• Utilize evidence-based practices, such as Motivational Interviewing, Harm Reduction Techniques, and Trauma- Informed Care principles.
• Work collaboratively with hospital staff regarding Transitional Care Planning
• Conduct outreach and engagement activities to facilitate linkage to the ECM program. Outreach and Engagement consists of phone calls, mailed information, and field visits.
• Accompany clients to office visits, as needed and appropriate.
• Evaluate progress and update goals.
• Provide mental health promotion.
• Arrange transportation
• Complete all documentation within the timeframes established by the individual action plans

KNOWLEDGE, SKILLS & ABILITIES:

? Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships.

? Long-time resident of the community with good knowledge of relevant resources. 

? Ability to do home visits and outreach.

? Experience with usage of EMR/EHRs/Care Management software.

? Strong organization skills and ability to manage and maintain a personal schedule.

? Ability to establish priorities and meet deadlines.

? Excellent oral and written communication skills.

? Ability to exercise judgment in the application of professional services.

? Active listening skills and genuine compassion for others.

? Enjoys collaboration within a team environment and working with people of different skills and experience.

? Able to maintain clear professional boundaries with patients and coworkers.

? Demonstrates cultural competency and ability to work with diverse groups of community clients.

? Comfortable using computer for documentation, communication, and organizing work.