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

Duties And Responsibilities

• 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.
• Makes regular contact with enrolled patients that includes at least one in-person encounter per month.
• 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.
• Collaborates 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.
• Performs other duties as assigned.

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).
• Licenses/Certifications: Driver's License (Required).