Lead Care Manager engaging with individuals living with Serious Mental Illness/Substance Use Disorder. Remote flexible with occasional on - site visits in California's Bay Area.
About the role
- Community Health Worker managing care for seniors in California through assessments and personalized plans. Working remotely and on-site to help seniors navigate health systems.
Responsibilities
- Enhance frail seniors' ability to age in place, manage their health, navigate the health care system, and live independently by providing person-centered care in accordance with ECM requirements.
- Collaborate in conducting comprehensive assessments to identify chronic conditions and psychosocial challenges affecting independent living.
- Perform assessments for Medi-Cal/Medicare dual-eligible members referred to Complex Care Management for Long-Term Services and Supports (LTSS) and assist the Registered Nurse in determining Nursing Facility Level of Care.
- Support member well-being through observation, positive communication, and motivational interviewing.
- Conduct face-to-face or phone visits to address care barriers, ensure engagement in primary and preventative care, and support individualized care plan implementation.
- Provides care coordination and empower members and their families in managing chronic conditions through coaching, education, healthcare navigation, advocacy, accompaniment to appointments and referrals to community, county, and state resources.
- Perform Enhanced Care Management (ECM) activities related to specific Populations of Focus (POF): Individuals Experiencing Homelessness, Individuals At Risk for Avoidable Hospital Or ED Utilization, Adults Living In the Community At Risk of LTC Institutionalization, Adult Nursing Facility Residents Transitioning Back to the Community.
- Implement personalized care plans tailored to the medical and social needs of high-risk members, incorporating realistic health goals supporting members inherent wishes.
- Actively participates in interdisciplinary planning and case conference meetings to ensure person-centered care and to ensure member receives support following discharge from an inpatient or institutional setting.
- Demonstrates strong organizational, follow-through, and engagement skills to achieve positive member outcomes.
- Adheres to SNP policies and ensures timely, accurate documentation of care plans, service plans, and progress notes within established timeframes.
- Network and build relationships with community business organizations like senior and wellness centers, housing outreach events, shelters, landlords, legal aid providers, etc.
- Utilizes department desktop procedures, workflows, job aids and training material.
- Identifies barriers to work processes and brings to the attention of the supervisor/manager.
- Actively Adheres to all quality, compliance, and regulatory standards.
Requirements
- High School Diploma required
- BILINGUAL- Must be bilingual in English/Spanish. (Test will be administered to assess proficiency.)
- At least 1 year of Community Engagement Experience required.
- Community Health Worker Certificate preferred.
- Experience within managed care, healthcare environment, lived experience or case management strongly preferred.
- At least 1 year of experience working with seniors, conducting home visits, and working remotely strongly preferred.
- Basic technical skills for functional area
- Basic problem-solving skills
- Good communication and interpersonal skills
- Basic interpersonal skills, including excellent written and verbal communication skills.
- Basic organizational skills.
- Basic critical thinking skills.
- Ability to collaborate effectively within a multidisciplinary team.
- Ability to appropriately maintain confidentiality.
- Basic understanding of NCQA standards, CMS and DHCS regulations.
- Basic knowledge of medical terminology and abbreviations.
- Basic understanding of local community resources for seniors.
Benefits
- An annual employee bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO)
- Eleven paid holidays per year
- Plus 1 floating holiday
- Plus 1 birthday holiday
- Excellent 401(k) Retirement Saving Plan with employer match and contribution
- Robust employee recognition program
- Tuition reimbursement
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