LEAD CARE MANAGER

Care Management

Provides comprehensive assessment of identified clients/members.
Develops person-centered care plans based on assessed client needs and goals.
Ensures the implementation of the assessment and care plan.
Provides direct care management services to clients in the Enhanced Care Management program.
May work collaboratively with ECM CHWs, as needed, to ensure implementation of care plan.
Forms authentic partnership with clients, uncovering what impedes better health outcomes, and actively works to find solutions.
Engages potential clients in health promotion and self-management.
Engages clients and builds trusting relationships.
Screens for and identifies social and behavioral health needs.
Arranges/assists with linkages to care, including appointments, transportation, etc.
Supports clients in developing health literacy; provides health promotion materials.
Advocates for clients with health care professionals; encourages treatment adherence; collaborates and coordinates with health care providers.
Accompanies clients to medical visits, as needed.
Works collaboratively with interdisciplinary team of nurses, social workers, and therapists.
Participates in case conferences and interdisciplinary team meetings to improve clients’ health outcomes.
Maintains accurate and timely care management records, including assessments, home visits, person-centered care plans, periodic reassessments, and progress notes related to client goals and interactions in the electronic health record (EHR).

Outreach And Community Connection

Lead in developing outreach plans and engaging new clients/members.
Builds and uses a community resource network for support with housing, food insecurity, employment, childcare, etc.,
develops and implements creative and resourceful strategies to meet client’s needs.
Conducts a variety of outreach activities to connect with potential clients.

Professional Conduct

Maintains confidentiality and treats participants and staff with dignity and respect at all times.
Communicates effectively and respectfully with people from diverse racial, ethnic, and cultural groups and from different backgrounds and lifestyles;
demonstrates compassion and sensitivity to their needs.
Develops and maintains positive community relationships with clients, coworkers, supervisors, partners, stakeholders, and the public.

Qualifications

• Required: Have a bachelor’s degree in social work, health and human services, or other related discipline and obtain a Community Health Worker (CHW) certificate of completion (2 classes) within one year of hire OR Hold a CHW certificate of achievement (16 units, including internship/practicum) at time of hire.
• Understanding of person-centered services and social determinants of health.
• Ability to develop, implement, and update care plans.
• Ability to be persistent, creative and resourceful in locating meaningful community resources and implementing care management plans.
• Demonstrates a high level of tolerance and empathy for individuals who present for services with urgent multiple care management and health needs.
• Strong interpersonal skills and the ability to work with individuals struggling with high level mental and physical health conditions, including navigate complex personalities, challenging behaviors, and sensitive situations with composure and resilience.
• Ability to grow and learn along with the program.
• Bilingual English/Spanish (preferred).

Preferred Experience

• With chronic illness.
• Familiarity with motivational interviewing techniques, de-escalation techniques, and trauma-informed care.

Other Requirements

• Must pass a TB test before first day of employment.
• Must receive an annual influenza vaccination or be willing to wear a protective face mask during government regulated influenza season.
• Must have a valid CA driver’s license, drive a motor vehicle incidental to the performance of the work and be insured.
• Lead Care Managers may transport clients and must pass a pre-employment drug screen and comply with periodic testing for drug use and alcohol misuse.
• Must be able to work at a computer for full workdays; some routine lifting and reaching requirements.
• Must pass a criminal background check and maintain a clean record.

Job Details

This is a FLSA non-exempt position.
This position is eligible for a $.40/$.10 per hour bilingual/biliterate differential after passing a test administered by the HR department.
This position is both on-site and, in the field, and may allow some remote work.
Hours of work are typically Monday-Friday between 9-5, however some evening and weekend work may be required.