Case Manager

Description

Position Summary:

As a key member of the Care Team, a care coordinator/case manager will oversee and coordinate the provision of services, including completion, but not limited to, of the Comprehensive Assessment (CA) and the Care Plan (CP), for eligible Medi-Cal patients with multiple chronic medical and mental health conditions as well as substance use disorders and homelessness. Care coordinator/care manager are responsible for fostering a care plan for patients with chronic conditions under the guidance of our Via Care Medical and Behavioral Health providers.

General Responsibilities:

· Offer services where the member lives, seeks care, or finds most easily accessible and within health plan guidelines using motivational interviewing and trauma-informed care practices

· In collaboration with the patient, complete the Comprehensive Assessment (CA)

· In collaboration with the patient, complete the individualized Care Plan (CP)

• Connect member to other social services and supports he/she may need and conduct follow-up to “close the loop” to ensure services were received

· Coordinate with co-located homeless services providers and assist with housing placement, when needed

• Advocate on behalf of members with internal and external health care professionals

• Work with hospital staff on discharge plan

• Accompany member to office visits, as needed and according to health plan guidelines

• Support and monitor treatment adherence (including medication)

• Arrange transportation

• Promote integrated care, ensuring that all team members are familiar with each patient’s CP

· Facilitate integrated/collaborative case coordination meetings; participate in monthly administration/evaluation meetings

· Collaborate with primary care providers and behavioral health providers to provide health and behavioral interventions that will maximize patient health outcomes;

· Conduct health and social assessments of client’s history with medical/dental/behavioral health services, social and economic resources for purposes of developing a comprehensive care plan and providing linkage to services

· Educate clients and family/supports with multiple chronic conditions about evidence-based standards of care and self-management of their illnesses

· Document work with clients through appropriate record keeping that follows VCCHC’s policies and procedures

· Attend appropriate community resource meetings/trainings, as assigned

· Work in collaboration with other departments and agencies

· Work with staff from other entities to coordinate discharge details for patients exiting care facilities (hospital, ED, treatment centers)

· Assist Program Director with monthly reports and audits

· Attends required trainings either in Los Angeles or within the state of CA

· Other duties as assigned:

· These duties may be modified and functions of the job description based on the needs of the organization.

Qualifications