Enhanced Care Management (ECM) Case Manager - (RN)

This position reports to the Enhanced Care Management (ECM) Program Manager this position provides support to the ECM Program to ensure engagement, enrollment and follow up on members related to the ECM as well as other clinical programs in which case management are central.

Under the supervision of the Enhanced Care Management Program Manager, the ECM Lead Care Manager is responsible for coordinating and implementing organization-wide Enhanced Care Management. Oversees and implements provision of the Enhanced Care Management (ECM) services; and identification and achievement of Care Plan goals and objectives with the member that meet their self-identified strengths and health care and psychosocial needs.

• Engages patients and offers and/or facilitates care management services where the patient lives, seeks care, or finds most easily accessible.
• Conducts comprehensive risk assessments and develops patient-centered Care Plans that includes goals based.
• on the patients’ physical and psychosocial health needs and considers their personal preferences.
• Oversees effective implementation of Care Plan, ensuring initial plan is drafted with 30 days from the patient’s.
• Enrollment and that it is updated as necessary, but no less than one per quarter, thereafter.
• Educates patients on self-management skills and/or recruits support from a caregiver/family member to support the accomplishment of the Care Plan.
• Supports health behavior change utilizing motivational interviewing and trauma-informed care practices.
• Monitors treatment adherence.
• Regularly initiates or participates in case conferences with clinical providers.
• Connects patient to social services, including housing, transportation, etc., as needed to achieve patient’s goals and well-managed care.
• Coordinates with hospital staff on discharge plan and with other transitional care as feasible.
• Accompanies patient to office visits, as needed and according to health plan guidelines.
• Maintains a regular contact schedule with enrolled patients that includes at least one in-person encounter per month.
• Document care management encounters in the Electronic Health Record (EHR) with the appropriate billing codes and internal tracking logs.
• Perform other duties as assigned.
• Open to seeing patients in person or their location of preference.

Qualifications:

• High School Diploma, bachelor's in social services preferred.
• 2 –3 years of experience in community health or social service setting required.
• 2 –3 years of case management/care coordination experience preferred.
• Case management: 1 year (Plus).
• Healthcare: 1 year (Plus).
• Bilingual required: English and Spanish or Armenian fluency required.
• Proficiency in Microsoft Office Suite products.
• Valid driver’s license and willing to drive to communities where ECM members live.
• Must be able to work in interdisciplinary team setting.
• Effective communication and interpersonal skills.
• Experience with Electronic Health Records preferred.
• Ability to independently seek out resources and work collaboratively.
• Ability to commute: SPA 6 and 8: Reliably commute.
• Willingness to travel: 75% (Preferred).
• License/Certification: Driver's License (Required).
• Work setting: Office/Telehealth.