Enhanced Care Management - Lead Care Manager - Carson

Counseling and Research Associates, Inc.; Carson (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Counseling and Research Associates, Inc. is seeking an ECM Lead Care Manager to act as the primary contact for participants in the ECM program.

You will develop comprehensive care plans with input from a multidisciplinary team, coordinating physical health, behavioral health, social needs, and long-term services. You will lead intake, assessments, direct services, and care transitions, ensuring trauma-informed, culturally competent care and effective collaboration with care partners.

Qualifications

• Bachelor's degree in psychology, social work or related field as required by the Department of Mental Health.
• AA degree in Human Services, Social Work, or Psychology plus two years' experience working with high-risk populations.

Responsibilities

• INTAKE: schedule appointments, conduct intakes, assess eligibility and needs, enroll in programs, and follow-up on referrals.
• ASSESSMENTS: perform initial and periodic client assessments and facilitate enrollment in services.
• DIRECT SERVICES: provide in-person, high-touch services and coordinate with the care team.
• CARE PLANNING: develop patient-centered, strength-based care plans with the member and providers.
• KNOWLEDGE: apply trauma-informed and culturally competent care, understand SDOH and core MH conditions.
• RESOURCES: build community networks and resources to meet identified needs.
• COLLABORATION: work with health plans and medical staff to coordinate care plans.
• SUPPORT: provide interventions and referrals, including potential home visits.
• TRANSITIONS: manage care transitions between providers and services.
• EDUCATION: educate patients on health maintenance and disease prevention.
• MONITORING: track and manage cases, monitor symptoms and utilization.
• DOCUMENTATION: maintain timely and accurate documentation and prepare reports.
• TRAVEL: travel to various environments as needed.
• MEETINGS: attend staff meetings and trainings.
• CONFIDENTIALITY: maintain client confidentiality across records.
• CRISIS: provide crisis intervention and therapeutic guidance.
• OTHER: meet with supervisor and perform other duties as assigned

Education

Bachelor's degree related to psychology or social work

AA degree in Human Services, Social Work, or Psychology + 2 years' experience

Job description

Enhanced Care Management - Lead Care Manager

The ECM Lead Care Manager serves as the primary point of contact for participants in the ECM program. The ECM Lead Care Manager develops a comprehensive Care Management Plan with input from a multidisciplinary care team, as well as the member, and coordinates all care needs and services, such as physical health, behavioral health, social needs, and long- term services and supports. The ECM Lead Care Manager reports to the ECM Director.

DUTIES:

1. 1. INTAKE: Schedules appointments and provides intakes per department guidelines and
   productivity goals and ensures appropriate intake steps are followed, including eligibility,
   assessment of needs, collecting patient data, enrolling in programs, developing care plan,
   and other steps as required by department guidelines. Able to follow-up on referrals and
   complete outreach activities within established timeframes.
2. 2. ASSESSMENTS: Conducts initial assessments and periodic reassessments of client's
   needs. Facilitates enrollment of patients in specialty care and services.
3. 3. DIRECT SERVICES: Provides direct in-person services for participants in their assigned
   case load. Performs services "in the field" with the purpose of maximizing high- touch
   services. Collaborates with the member to help them build upon resiliencies; healthy
   lifestyle choices; self-care mgt; strengthen skills to enable the member to identify and
   access resources to assist them in managing their own conditions and prevent other
   chronic condition. Schedules weekly and monthly phone calls with members.
4. 4. CARE PLANNING: Able to develop patient-focused, individual plans of care that are
   person-centered, and strength based in partnership with the member and other
   providers. Is able to communicate and coordinate with various entities associated with
   the members care team and leads the provision and coordination of services.
5. 5. KNOWLEDGE: Demonstrates an understanding of trauma-informed care and strength
   based and culturally competent services. Demonstrates an understanding of "core"
   medical/MH conditions and challenges faced by the ECM target populations and
   knowledge of Social Determinants of health (SDOH). Demonstrates the ability to
   integrate Motivational Interviewing throughout all interactions with the member.
6. 6. RESOURCES: Develops resources and community networks and services that can meet
   the members identified needs.
7. 7. COLLABORATION: Able to work in close collaboration with health plan partners and
   medical staff to develop, implement, and coordinate care plans for clients with chronic
   conditions such as diabetes, asthma, behavioral health conditions.
8. 8. SUPPORT: Provides basic and intensive individual support, based on client need. Support
   may include providing interventions, providing internal and community services referrals,
   and more intensive support which may include a home visit.
9. 9. TRANSITIONS: Facilitates care transitions between providers, partners, referral sources
   and specialty care providers. Demonstrates the ability to help the member transition
   safely and easily between different levels of care and delivery systems and to execute
   needed care coordination triggered by care transitions.
10. 10. EDUCATION: Educates patients about health maintenance and disease prevention.
11. 11. MONITORING: Tracks, monitors, and actively manages assigned patient cases to ensure
    coordination of care, retention of patient, and ensuring a high level of utilization is
    maintained. Monitors and reports changes in patient symptoms or behaviors.
12. 12. DOCUMENTATION: Completes all required documentation accurately, thoroughly and in
    a timely manner, in accordance with department standards. Assists in preparing reports
    as required.
13. 13. TRAVEL: Travels independently to various environments (buildings with stairs, various
    communities, schools, etc.).
14. 14. MEETINGS: Attends all staff meetings, in-service training and conferences as required
    and scheduled.
15. 15. CONFIDENTIALITY: Maintains strict confidentiality over all records and information
    relative to the client.
16. 16. CRISIS: Ensures the safety of clients by providing direct crisis intervention and
    therapeutic guidance.
17. 17. OTHER: Meets regularly with supervisor to review cases and performs other duties as
    assigned by the supervisor.

QUALIFICATIONS:

1. 1. A Bachelor's degree related to the fields of psychology, social work or other majors defined
   by the Department of Mental Health as a related degree)- OR- an AA degree in Human
   Services, Social Work, or Psychology plus two years' experience working with high risk
   populations.
2. 2. Two years case management experience, demonstrating familiarity and comfort level in
   working with ECM populations.
3. 3. Valid California Driver's License, good driving record, and must be able to drive to fulfill the
   duties of the position.