Care Manager

Aria Community Health Center; Lemoore (CA); On-site; USD 50,000 - 72,000; Full time

Benefits offered by this job

403(B) matching

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Paid Holidays

Vacation Pay

Sick Pay

Job summary

Aria Community Health Center seeks a Care Manager to support the Patient Centered Medical Home program across Tulare, Fresno, and Kings counties. You will conduct assessments, develop care plans, and coordinate with a multidisciplinary team to meet patient goals.

The role requires bilingual English/Spanish abilities, strong communication, and the ability to connect patients with essential services. Experience in a clinic setting and knowledge of community resources are valued.

Qualifications

• Bilingual English/Spanish required.
• 1 year experience in a clinic or healthcare setting.
• Associate degree in Health Sciences or related field preferred; certificates can substitute for experience.
• Motivational interviewing and trauma-informed care knowledge is preferred.
• Ability to navigate resources and community services to support patients.

Responsibilities

• Conduct initial and ongoing assessments of medical, mental health, social, housing, and functional needs.
• Develop individualized care plans with patient and provider input.
• Advocate for patients across internal and external teams.
• Connect patients to services to reduce barriers to care (shelter, transportation, food, etc.).
• Provide health promotion and self-management training to patients and families.

Skills

Bilingual English/Spanish

Care coordination

Motivational interviewing

Communication skills

Teamwork

Organization

Education

Associate degree preferred

Nursing Assistant / Medical Assistant / Home Health Aide certificates as substitute

Tools

Electronic Health Record (EHR)

Microsoft Office

Job description

At ACHC, we are committed to improving the health and well being of our communities. As a Federally Qualified Health Center and licensed primary care clinic, we provide comprehensive medical and dental services, along with specialized care in Chiropractic, Internal Medicine, Neurology, Pediatrics, Psychology, Podiatry, and Optometry. With clinics located across Fresno, Kings, and Tulare counties, our team works together to deliver accessible, high quality care to every patient.RESPONSIBILITESAssists Clinic Operations and provides care coordination support to the Aria Community Health Center (ACHC) Patient Centered Medical Home Care Management Program for patients residing in Tulare, Fresno and Kings County. This position is pivotal in ensuring all needs of the patient are identified and coordinated within the organization as well as with outside providers to improve health outcomes. The needs of the patient may include complex health conditions, mental health diagnosis, shelter concerns, financial instability, extreme poverty, transportation, or food insecurity. The Care Manager will be under direct oversight of Clinic Operations for chart review. The Care Manager provides initial outreach to potential eligible patients and works with the eligible patients and care coordinators to meet established goals while using patient centered methodologies. Understanding motivational interviewing, trauma informed care, and persuasion skills is fundamental to meeting the objectives of this position.ESSENTIAL JOB FUNCTIONS & RESPONSIBILITIESConduct initial and ongoing assessments to identify medical, mental health, substance use, social, housing, and functional needs.Carries a caseload of patients consistent with PCMH guidelines.Develop individualized, whole person care plans with patient and provider inputAdvocate for patients in various settings including internal multi disciplinary team meetings, insurance carriers, outside health providers, social workers, resource providers, etc.Connect patients to needed services that will reduce barriers that impact their health including shelter, transportation, food access, in home care, etc.Use motivational interviewing and trauma informed care practices to ensure patients meet the goals established by Clinical Team.Engage with patients that meet program eligibility requirements.Provide health promotion and self management training to individual patients and their families.Conduct regular telephonic outreach and follow up with Patients.Complete comprehensive assessments (SDOH).Complete enrollment screening and documentation, Health Action Plan reports, and other necessary reports.Obtain required Care Management enrollment consents.Function as a patient advocate.Meet care management documentation expectations.Promote wellness and prevention.Verbally present patient case to multi disciplinary team.Distribute health promotion materials.Responsible for accurate and timely documentation which includes but is not limited to program enrollment, assessment, updated activity/progress notes, resource access applications, releases of information, and other forms necessary to document services.Support other Care Managers with delegated tasks.Ensures the privacy and security of Protected Health Information (PHI) as outlined in ACHC policies and procedures.Other duties as assigned, including but not limited to verification of insurance eligibilities and submission of treatment authorizations.Education:Preferred: Associate degree in Health Sciences or Human Services, or in a closely related field.Experience:1 year experience within a clinic or healthcare setting.Required: Bilingual English/Spanish.May substitute one year experience for any of the following Certificates/Licenses: Nursing Assistant, Medical Assistant or Home Health Aide.Skills / Ability:Basic understanding of best practices and/or lifestyle recommendations in common complex conditions including asthma, depression, diabetes, heart conditions, and hypertension.Basic understanding of various government and nonprofit resources including public assistance, rent/utility assistance, food distribution, etc. Experience with County resources is preferred.Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi disciplinary teams.Exercise appropriate judgment and decision making.Communication skills including interpersonal, verbal, and written.Knowledge and experience in motivational interviewing is preferred.Able to sufficiently engage members and providers on the phone and in person or via email.Organization skills, including prioritizing tasks and time management.Highly skilled interpersonally, with excellent teamwork and relationship skills.Ability to work well under pressure with experience in establishing priorities, meeting deadlines, and adapting quickly to change.Ability to independently seek out resources as well as work collaboratively in solving barriers to care.Ability to read, understand and follow oral and written instructions including internal policies and communications as well as applicable local, State, and Federal regulations.Proficient with various software systems including Microsoft Office Suite and Electronic Health Record (EHR) programs.Demonstrates ability to work in a regulatory climate that includes oversight by State and Federal entities, payer contracts, etc.Possess a genuine respect for others and acceptance of their individual, social and cultural traits. Experience working with traditionally marginalized populations is preferred.Able to travel and attend professional meetings, conferences, trainings, and clinic sites.PHYSICAL/COGNITIVE REQUIREMENTSThe physical and cognitive demands listed below represent essential functions of this position and are required with or without reasonable accommodation:Hearing: Sufficient to engage with patients and staff in person and by telephone.Speaking: Clear verbal communication to convey medical and operational information.Vision: Visual acuity adequate for reading printed materials and viewing electronic screens.Cognitive Abilities: Aptitude to complete tasks, including abilities such as learning, remembering, focusing, categorizing, and integrating information for decision making, problem solving, and comprehending.Motor Function & Mobility:Ability to move within the work environment to complete tasks and interact with others.Occasional lifting and carrying of items up to 10 pounds without assistance.Frequent standing, sitting, bending, reaching, and other movements typical of a standard workday.Regular use of hands and fingers for typing, writing, operating tools or equipment, and handling materials.Some pushing and pulling required during daily tasks.NOTE: The essential job functions for this position include but may not be limited to those listed in this job description. Employees hired for this position must be able to perform the essential functions of this job without imposing significant risk of substantial harm to the health or safety of themselves or others.BENEFITS403(B) matchingMedical InsuranceDental InsuranceVision InsuranceLife InsurancePaid HolidaysVacation PaySick PayEEO STATEMENT:Aria Community Health Center is an equal opportunity employer and does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.Aria Community Health Center participates in E-Verify.