Nurse, Licensed Vocational

POSITION TITLE:  JOB CLASSIFICATION:

ECM Lead Care Manager                                                               NON-EXEMPT

TITLE OF IMMEDIATE SUPERVISOR: 

Chief Operations Officer – Primary Care

DIVISION:  

COMMUNITY CARE CLINIC

POSITION OBJECTIVE/SUMMARY:

The ECM (Enhanced Care Management) Lead Care Manager will outreach and enroll clients in enhanced care management and be responsible for overseeing the development and implementation of comprehensive care plans for high-need, high-risk patients within the ECM program. They will work with leadership, providers and managed care to determine the needs of high acuity, vulnerable patients and provide basic housing assistance and patient-tailored intensive case-management, developing a care/service plan, providing linkages to medical, psychiatric, social, educational and other services as needed. This role will coordinate care activities, collaborate with interdisciplinary teams and ensure optimal care delivery to improve patient outcomes. They will also collaborate with the Community Supports Program staff to provide team-based, patient-centered care management for homeless and at-risk of homelessness patients. They will work with medical/behavioral providers and patients to implement and perpetuate treatment and chronic disease self-management for patients enrolled in ECM within as well as outside of the clinic. They will develop and maintain Care Management Plans and review with the ECM team for compliance. The ECM Lead Care Manager will act as a point of contact for both patients and healthcare providers, ensuring that the care management process is efficient, effective and compliant with applicable regulations.

MINIMUM QUALIFICATIONS REQUIRED FOR THIS POSITION:

• Bachelor’s degree in Nursing, Social Work, Public Health, Healthcare Administration, or a related field.
• Current and valid licensure as a Licensed Vocational Nurse (LVN).
• Minimum of 5 years of experience in care management preferred.
• Previous experience with ECM, complex care management, or clinic setting preferred.
• Strong knowledge of healthcare delivery systems, care coordination, and patient advocacy.
• Excellent decision making and problem-solving ability.
• Excellent analytical skills required.
• Must be organized and detail oriented.
• Good verbal and written communication, interpersonal skills.
• Excellent communication and interpersonal skills, with the ability to work collaboratively with diverse teams and patients.
• Ability to manage multiple priorities, meet deadlines, and handle complex situations.
• Proficient in the use of electronic health records (EHR) and care management software.

GENERAL STATEMENT OF FUNCTIONS:

• Engage eligible Members through personalized interaction and utilize motivational interviewing, trauma-informed care and harm-reduction techniques.
• Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the Member and non-duplication of services.
• Oversee the provision of ECM services and ensure the implementation of the Comprehensive Assessment and Care Management Plan.
• Offer services where the Member lives, seeks care, or is most convenient, in line with Medi-Cal Health Plan (MCP) guidelines.
• Collaborate with hospital staff on discharge planning and act as the single point of contact for the member.
• Provide health promotion and self-management training.
• Attends and maintains records of required annual training in cultural competency and person-centered care planning.
• Responsible for quality measures and reporting for the team.
• Support the vital role of the Primary Care Provider (PCP) in care coordination.
• Outreach and enroll clients in enhanced care management.
• Responsible for patient outreach for preventative or chronic care services with the priority going to overdue patients.
• Engage eligible ECM Members.
• Accompany ECM Member to office visits, as needed, and in the most easily accessible setting, within MCP guidelines.
• Arrange transportation to and from medical appointments, specialists and other healthcare needs.
• Assist with linkage to social supports.
• Call Member to facilitate visit with care coordinator and members of the healthcare team.
• Connect ECM Member to other social services and supports the Member may need.
• Advocate on behalf of the Member with healthcare professionals.
• Use motivational interviewing, trauma-informed care and harm-reduction approaches.
• Monitor treatment adherence, including medication.
• Develop and maintain initial assessment within ECM time guidelines.
• Develop and maintain care management plans and review for compliance.
• Coordinate support services and review progress toward goals for patient.
• Responsible for billing as provided by managed care.
• Attend ECM training, meetings and educational webinars.
• Increase access to care by monitoring patient’s missed office visits and getting them into the office or seen at home.
• Participate actively in team huddles, clinic and MCP meetings and educational webinars.
• Assist in providing interested individuals access to a variety of community-based services, which include and are not limited to transportation, food and housing services.
• Provide information on ECM services, clinic services and health awareness.
• Educate clients regarding available benefits and provide warm hand-off to Case Manager.
• Coordinate patient transportation with Case Manager to needed services and accompany patient if needed.
• Fulfill any Population of Focus-specific roles as stipulated by DHCS in the DHCS ECM.
• Other duties as assigned.