Lead Case Manager - CalAIM Care Coordinator

AMPLA HEALTH; Chico (CA); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

4 weeks PTO

9 paid holidays

401k and profit sharing

Monday to Friday

Job summary

Ampla Health in California is seeking a compassionate Lead Case Manager to coordinate care for high-risk patients under CalAIM ECM. You will conduct outreach, enroll eligible members, and coordinate transitions of care with hospitals, primary care, and social services.

Under the supervision of the Enhanced Care Coordination Program Manager, you will develop individualized care plans, monitor treatment adherence, and advocate for patient needs, ensuring timely follow-ups and data quality while

Qualifications

• High school diploma required; Medical Assistant certification preferred.
• Current CPR certification.
• Valid CA driver’s license and proof of insurance.
• Excellent communication, problem-solving, and patient engagement skills.
• Bilingual and/or experience working with diverse populations is a plus.

Responsibilities

• Conducts daily outreach to assigned panel of patients within geographical areas that are reasonable and easily accessible.
• Actively enrolls all eligible patients into the California Advancing and Innovating Medi-Cal (CalAIM) program.
• Secures patient discharge instructions and uploads to patient chart.
• Uses the Ideal Transitions of Care Framework for coordinating care for high-risk patients.
• Provides medication adherence support through facilitation, patient education, and service linkages.
• Conducts comprehensive patient assessments.
• Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
• Assists patients in establishing and achieving care and treatment goals through a documented care plan.
• Coordinates with Ampla Health primary care and other departments to achieve patient centered care and optimize patient communication and care.
• Coordinates care with other organizations and other services as needed.
• Assists with referring patients to the Chronic Care Management Program when needed.
• Maintains an accurate record of outreach, communications, patient needs, and services.
• Works to achieve “transition of care” program metrics as detailed to Table 1, below.
• Supports Ampla Health’s mission by providing superior customer service and respecting patients.
• Strengthens clinical and quality teamwork and rapport through strong work ethic and individual accountability.
• Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
• Treats patients with empathy and respect and conduct oneself professionally.

Skills

Communication

Problem Solving

Patient Engagement

Bilingual

Education

High School Diploma

Medical Assistant certification

CPR Certification

Job description

Ampla Health in California is seeking a compassionate Lead Case Manager to coordinate care for high-risk patients under CalAIM ECM. You will conduct outreach, enroll eligible members, and coordinate transitions of care with hospitals, primary care, and social services.

Under the supervision of the Enhanced Care Coordination Program Manager, you will develop individualized care plans, monitor treatment adherence, and advocate for patient needs, ensuring timely follow-ups and data quality while