Job description
Under the direction of the Assistant Director and/or Clinical Consultant, 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 member access to care in a timely and cost-effective manner. The LCM collaborates and communicates with members, caregivers/family support persons, other providers, and the Health Homes Care Team in order to promote wellness, recovery, independence, resilience, and member empowerment, while ensuring access to appropriate services and maximizing member benefit. The LCM also serves as a clinical advocate for members, an active interdisciplinary team member, a liaison with other Center programs and external health and social service providers in the community.
DUTIES AND RESPONSIBILTIES:
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Assess member needs in the areas of physical health; mental health; SUD; oral health; palliative care; memory care; trauma- informed care; social supports; housing; vocational/employment; wellness; and referral and linkage to community-based “longer” term services and supports.
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Oversees the development of the Health Action Plan and the implementation of Health Action Plan services
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Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services.
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Connect member to other social services and supports that are needed (e.g., community support group).
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Given consent from the member advocate on behalf of members with health care professionals (e.g., PCP, etc.).
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Utilize “evidence-based” practices, such as Motivational Interviewing, Stages of Change, Harm Reduction Techniques, and Trauma- Informed Care principles.
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Work collaboratively with hospital staff regarding Discharge Planning.
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Conduct outreach and engagement activities in order to facilitate linkage to the ECM program. Outreach and Engagement consists of phone calls, mailed information, and field visits.
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Accompany members to office visits, as needed and appropriate.
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Evaluate progress and update goals.
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Provide mental health promotion.
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Arrange transportation (e.g., ACCESS).
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Complete all documentation, including Outcome Measures within the timeframes established by the individual plans and the Center.
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Attend weekly staff/team meetings and supervision.
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Attend training as assigned (e.g., ACEs Certification).
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Bachelor’s Degree.
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Qualifying Experience-previous experience with providing Case Management Services and/or care coordination for vulnerable and /or underserved and diverse populations.
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Valid CA Class C Driver License in good standing and have personal, valid insurance and be able to be insured by the Center’s insurance Carrier.
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Must act in accordance with all Health Insurance Portability and Accountability Act (HIPAA) of 1996 and related State law, confidential requirements. Must have successfully completed the Center’s HIPAA training, pass the HIPAA test, and receive the Certification of Compliance.
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Regular attendance is an essential function of the job.
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Interacting with other employees at work is an essential function of the job.
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Arriving at work on time and not leaving early is an essential function of the job.
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Bilingual ability is a plus.
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