Chronic Care Manager

Description:

The Care Coordinator works as part of the multi-disciplinary team, offering enhanced case management and other social services to adults who may have complex health conditions, are/have been homeless, and possibly have substance abuse issues. This is a Non-clinical position.

The Enhanced Care Manager works under the supervision of a clinical team of nurses and provides care management services to eligible Medi-Cal members. This position requires you to participate in the planning, development, implementation, and evaluation of services as per requirements and guidelines. Offering case management services to qualifying Medi-Cal members, focusing on community-based healthcare services. This includes creating care plans and formalized goal setting. Depending on the client’s needs, you may be required to accompany the member to appointments, schedule follow-up appointments, and assist with housing.

Enhanced Care Management program and Community Support services provide eligible Medi-Cal beneficiaries experiencing or at risk of homelessness with enhanced care management and coordination services. Enhanced Care Management coordinates a full range of physical health, behavioral health, and community-based services to ensure the individuals served have access to and receive the services necessary to address their complex medical needs and chronic conditions.

Responsibilities include:

• Connects with the Medi-Cal members via phone or in-person to facilitate engagement, assessment, follow-up
• Provide education/training visits to develop and address the Care Plan.
• Conducting initial assessments and periodic reassessments of client’s needs
• Leads the provision and coordination of services and direct services to the participants in your assigned caseload. (Caseload up to 50 members)
• Developing patient-focused care plans in partnership with other providers and the client
• Working with medical staff to develop, implement, and coordinate care plans for clients with chronic conditions such as diabetes, asthma, behavioral health conditions
• Advocate on behalf of Members with healthcare professionalism
• Responsible for driving a positive patient customer service experience through multiple support channels, including the patient portal, clinical platform, and messaging systems
• Respond to inquiries from patients and outside agencies and refer, when necessary, to the appropriate person or department
• Adhere to all organizational policies, HIPAA regulations, and company guidelines.
• Schedule weekly and monthly phone calls with members
• Monitor, document, and report changes in patient symptoms or behavior
• Monitor and maintain goal levels of calls per assigned caseload
• Capturing patient demographics information, insurance information, and structured data into patient management systems during each phone encounter
• Communicate to PCP any significant changes in patient concerns along with any updates on patient status
• Educate patients about health maintenance and disease prevention
• Completes all required documentation accurately, promptly, and thoroughly following department standards.
• Conducts initial and ongoing assessment of client’s health and/or support service needs. Sets the level of client need.
• Facilitates care transitions between providers, partners, referral sources, and specialty care providers.
• Follows up on referrals within established timeframes. (24 hrs once the referral is received)
• Facilitates enrollment of patients in specialty care and services.
• Schedules appointments and provides intakes per department guidelines and productivity goals.
• Ensure appropriate intake steps are followed, including eligibility, assessment of needs, collecting patient data, enrolling in programs, developing a care plan, and other steps as required by department guidelines.
• Provides basic and intensive individual support based on client needs. Support may include interventions, internal and community services referrals, and more intensive support, including a home visit.
• Tracks, monitors, and actively manages assigned patient cases to ensure care coordination, patient retention, and high utilization are monitored
• Performs other duties as assigned by team leads, supervisors, and managers.

Care Plan and Assessment Functions

• Complete assessments and develop care plans for the Medi-Cal member
• Review care plans routinely to ensure that appropriate care is being received.
• Ensure that monthly visit notes reflect the needs and goals of the member and that the member is following the care plan.
• Review patient care plans for appropriate goals, problems, approaches, and revisions based on patient-centered needs.

Qualifications

• Certified Nursing Assistant (CNA) certification
• Strong customer service skills
• Experience in developing and implementing care plans
• Proficient in medical administrative support and office experience
• Familiarity with medical records and EHR systems
• Knowledge of medical terminology and HIPAA regulations
• Ability to manage patient service and clerical tasks efficiently

Benefits

Pay: From $17.00 per hour

Hybrid Position

Job Type: Full-time

Pay: $16.00 - $19.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Health insurance
• Paid time off

Schedule:

• Choose your own hours
• Monday to Friday
• Weekends as needed

Work Location: In person

Salary : $16 - $19