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Lead Case Manager
2 months ago
The Good Seed CDC is seeking a highly skilled and compassionate Lead Case Manager to join our Enhanced Care Management team. As a key member of our team, you will play a critical role in improving the health status of our members through an integrated managed healthcare delivery system.
Key Responsibilities- Community Outreach and Engagement: Develop and implement strategies to engage patients and offer care management services where they live, seek care, or find most easily accessible.
- Care Plan Development: Conduct comprehensive risk assessments and develop patient-centered Care Plans that include goals based on the patient's physical and psychosocial health needs and personal preferences.
- Implementation and Monitoring: Oversee the effective implementation of Care Plans, ensuring initial plans are drafted within 30 days of enrollment and updated as necessary, but no less than one per quarter thereafter.
- Patient Education and Support: Educate patients on self-management skills and/or recruit support from caregivers/family members to support the accomplishment of Care Plans.
- Health Behavior Change: Support health behavior change utilizing motivational interviewing and trauma-informed care practices.
- Treatment Adherence: Monitor treatment adherence and regularly initiate or participate in case conferences with clinical providers.
- Social Services Coordination: Connect patients to social services, including housing, transportation, etc., as needed to achieve patient goals and well-managed care.
- Discharge Planning: Coordinate with hospital staff on discharge plans and with other transitional care as feasible.
- Regular Contact and Documentation: Maintain a regular contact schedule with enrolled patients, including at least one in-person encounter per month, and document care management encounters in the Electronic Health Record (EHR) with appropriate billing codes and internal tracking logs.
- Empathy and Advocacy: Demonstrate empathy, advocacy, cultural competency, and follow-up assistance to help clients access services needed to build and sustain healthy lives.
- Critical Thinking and Problem-Solving: Possess critical thinking skills and a desire to help those in need, with the ability to solve complex and comprehensive problems.
- Communication and Interpersonal Skills: Exhibit excellent communication skills, both written and verbal, and the ability to work in a rapidly evolving work environment.
- Leadership and Collaboration: Provide support to the Enhanced Care Management Program to ensure engagement, enrollment, and follow-up on members related to the ECM and other clinical programs.
