Lead Care Manager

Eisner Health; Los Angeles (CA); Hybrid; USD 75,000 - 105,000; Full time

Benefits offered by this job

PTO accrual

Paid holidays

Jury duty pay

Health insurance (PPO)

HSA/Flexible spending

401k

Tuition reimbursement

Parking or transit

Mileage reimbursement

Life insurance

Long-term disability

Job summary

Eisner Health is seeking a Lead Care Manager to coordinate Enhanced Care Management for enrolled patients in a hybrid work setting in Los Angeles. You will serve as the primary liaison among care team members and patients, ensuring care plans address medical and psychosocial needs to reduce preventable hospital use.

Required are a Bachelor's degree, 2 years in community health, English/Spanish fluency, and strong communication.

Qualifications

• Bachelor Degree required
• 2 years of experience in community health or social service setting required
• Case management / care coordination experience
• English and Spanish fluency required
• Proficiency in Microsoft Office Suite products
• Ability to travel locally to Eisner Health sites and communities where ECM patients 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

Responsibilities

• Engages eligible ECM patients and facilitates care management services where the patient lives or seeks care.
• Develops patient-centered Care Plans with goals based on health and psychosocial needs.
• Ensures Care Plan implementation and quarterly updates.
• Educates patients on self-management and engages caregivers as needed.
• Supports health behavior change using motivational interviewing and trauma-informed care.
• Monitors treatment adherence and progress.
• Participates in case conferences with providers and ECM consultants.
• Connects patients to social services like housing and transportation.
• Coordinates with hospital staff on discharge and transitional care.
• Accompanies patients to office visits as needed.
• Maintains regular in-person encounters monthly.
• Documents encounters in EHR with billing codes.
• Tracks outreach attempts in ECM and i2i systems.
• Supports completion of ECM monthly reports.
• Performs other duties as assigned

Skills

Bilingual English/Spanish

Interdisciplinary teamwork

Effective communication

Resource coordination

Travel locally

Problem solving

Education

Bachelor's degree

Tools

Microsoft Office

Job description

*This position is hybrid status, which requires a combination of remote and on-site work. Will be assigned an estimated 2-3 days onsite per week.

The Lead Care Manager serves as the primary contact to patients enrolled in the Enhanced Care Management (ECM) Program and plays a central role connecting the care team members with the patient and with each other for optimal communication about the patient’s Care Plan. The ultimately goal of ECM is to effectively manage the patients over the continuum of care to ensure that their medical and psychosocial needs are met for a well-managed health condition and to minimize the likelihood of preventable hospital and emergency department utilization.

ESSENTIAL DUTIES

1. Engages eligible ECM patients and offers and/or facilitates care management services where the patient lives, seeks care, or finds most easily accessible.

2. 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.

3. Oversees effective implementation of Care Plan, ensuring initial plan is drafted with 60 days from the patient’s enrollment and that it is updated as necessary, but no less than one per quarter, thereafter.

4. Educates patients on self-management skills and/or recruits support from a caregiver/family member to support the accomplishment of the Care Plan.

5. Supports health behavior change utilizing motivational interviewing and trauma informed care practices.

6. Monitors treatment adherence.

7. Regularly initiates or participates in case conferences with providers and/or ECM Clinical Consultants.

8. Connects patient to social services, including housing, transportation, etc., as needed to achieve patient’s goals and well-managed care

9. Coordinates with hospital staff on discharge plan and with other transitional care as feasible.

10. Accompanies patient to office visits, as needed and according to health plan guidelines[2].

11. Maintains a regular contact schedule with enrolled patients that includes at least one in-person[3] encounter per month.

12. Document care management encounters in the Electronic Health Record (EHR) with the appropriate billing codes.

13. Documents outreach attempts in ECM tracking spreadsheet and i2i tracking group.

14. Support the completion of ECM monthly reports for each Health Plan.

15. Perform other duties as assigned.

POSITION REQUIREMENTS

1. Bachelor Degree required

2. Two years of experience in community health or social service setting required

3. Case management / care coordination experience

4. English and Spanish fluency required

5. Proficiency in Microsoft Office Suite products

6. Ability to travel locally to Eisner Health sites and communities where ECM patients live.

7. Must be able to work in interdisciplinary team setting

8. Effective communication and interpersonal skills

9. Experience with Electronic Health Records preferred

10. Ability to independently seek out resources and work collaboratively

Benefits:

• PTO Accrual rate of 7.08 hours per pay period (26 pay periods per year).
• 9 Paid Holidays.
• 40 hours of paid Jury Duty time per year.
• Medical, Dental, & Vision insurance (PPO option available).
• Health Insurance subsidy.
• Flexible Spending Accounts (Healthcare, Dependent Care, & Transportation).
• Employer-Sponsored life insurance & long term disability.
• 30 covered visits for Chiropractic or Acupuncture visits.
• 401k retirement plan with a 3% employer contribution.
• Professional Development: Tuition reimbursement.
• Parking or Public Transportation Reimbursement.
• Mileage reimbursement for eligible business-related travel.

#EHINDEED

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.