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Lead Care Manager/care Coordinator
4 months ago
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.
- 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
