Description

Position Summary:

The Enhanced Care Management (ECM) Case Manager LVN, under the supervision of the Case Management Manager, is responsible for addressing the clinical and non-clinical needs of members with the most complex medical and social needs through systematic coordination of services and comprehensive care management. ECM is intended to be interdisciplinary, high touch, person-centered and provided primarily through in-person interactions with members where they live, seek care, and/or prefer to access services. The case manager works with members that have chronic health conditions, are homeless or at-risk, with high hospital admissions, substance abuse, behavioral needs, and/or transitioning from incarceration. Using excellent communication skills, case managers will provide services and coordination with members to ensure continuity of care across health and social service programs and community based and long term-support service (LTSS) programs. This position requires strong interpersonal and organizational skills to build rapport with members, coordinate referrals, and care amongst various healthcare providers and community services. The case manager also works with the member’s inter-disciplinary team (ICT) supporting the member. The case manager engages member and member support systems to define priorities that are central to the member’s desired needs and goals.

Compensation:

The initial pay range for this position upon commencement of employment is projected to fall between $32.00and $38.00. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Requirements

Job Duties and Responsibilities:

· Effectively manage and maintain a caseload of assigned ECM members.

· Conduct a comprehensive assessment to develop a comprehensive, individualized, person-centered care plan with input from the member (and/or their parent, caregiver, guardian) to prioritize, address, and communicate strengths, risks, needs, and goals.

· Engage with each member (and/or their parent, caregiver, guardian) authorized to receive ECM primarily through in-person contact and provide culturally appropriate and accessible communication.

· Identify necessary clinical and non-clinical resources that may be needed to appropriately assess member health status and gaps in care and may be needed to inform the development of an individualized Care Management Plan.

· Ensure member’s care plan, incorporate identified needs and strategies to address needs, including, but not limited to, physical and developmental health, mental health, dementia, SUD, LTSS, oral health, palliative care, necessary community-based and social services, and housing.

· Ensure the member is reassessed at a frequency appropriate for the member’s individual progress or changes in needs and/or as identified in the Care Management Plan.

· Ensure the Care Management Plan is reviewed, maintained, and updated under appropriate clinical oversight. Perform care coordination of care services necessary to implement the care plan.

· Gather information, present, and participate in Interdisciplinary Care Team (ICT) meetings.

· Organize member care activities, as laid out in the care plan; sharing information with those involved as part of the member’s multi-disciplinary care team; and implementing activities identified in the care plan.

· Provide support to engage the member in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment.

· Communicate the member’s needs and preferences in a timely manner to the member’s multi-disciplinary care team.

· Ensure regular contact with the member (and/or their parent, caregiver, guardian) when appropriate, consistent with the care plan and to monitor the member’s conditions, health status, care planning, medications usages and side effects.

· Ensure care is continuous and integrated among all service Providers and referring to and following up with primary care, physical and developmental health, mental health, SUD treatment, LTSS, oral health, palliative care, and necessary community-based and social services, including housing, as needed.

· Provide services, such as coaching, to encourage and support members to make lifestyle choices based on healthy behavior, with the goal of promoting effective self-management skills.

· Support members in strengthening skills that enable them to identify and access resources to assist them in managing their conditions and preventing other chronic conditions.

· Use evidence-based practices, such as motivational interviewing, to engage and help the member participate in and manage their care.

· Provide transitional care services, including completion of discharge risk assessment and coordinating any follow up provider appointments and support services to facilitate safe and appropriate transitions from one setting or level of care to another.

· Coordinate medication review/reconciliation and provide adherence support and referral to appropriate services.

· Determine appropriate services to meet the needs of members, including services that address SDOH needs, including housing, and services offered by Community Supports.

· Coordinate and refer members to available community resources and follow up with members (and/or parent, caregiver, guardian) to ensure services were rendered (i.e., “closed loop referrals”).

· Work collaboratively and consult with other staff (RN Case Manager, Medical Director, Case Management leadership) to review clinical documentation and implementation, including comprehensive assessments, medication review, and member care plans.

· Attend mandatory departmental and staff meetings.

Assist with training and orientation.

Qualifications:

· Education: Education: High School diploma or GED.

· Licensure: Current California LVN license required.

· Experience: Minimum of two (2) year experience working in a health care setting; managed care or IPA experience preferred.

· Demonstrated knowledge of nursing processes, case management, and continuity of care.

· Ability to respect the needs of members, support givers, team members, and others, and provide excellent customer service.

· Willingness to collaborate as part of a team with professionals at all levels to achieve goals and remove barriers to member health.

· Sensitivity to members' social, cultural, language, physical, and financial differences.

· Ability to work with members and influence behavior through negotiation of care goals and support of member self-management.

· Strong problem-solving skills and ability to identify issues and propose solutions.

· Ability to prioritize tasks based on changes in member situations and needs.

· Ability to work independently, organize and prioritize multiple tasks throughout the day.

· Strong attention to detail and ability to be accurate, thorough, and persistent in problem-solving and task completion.

· Excellent verbal and written communication skills, with the ability to communicate effectively with all levels of the organization and members.

· Proficiency in creating professional documents with proper grammar and punctuation.

· Ability to maintain professionalism and adapt to a changing environment.

· Ability to understand and communicate complex health and benefit information.

· Proficient in the use of common office technology, including electronic Case Management systems.

· Reliable in attendance and adherence to work schedule and business dress code.

· Ability to always maintain strict confidentiality.

Other Requirements:

· Possession of valid driver’s license

· Proof of state-required auto liability insurance.