Lead Care Manager - ECM

DUTIES:

Outreach to eligible health plan members to enroll them into Enhanced Care Management per protocols. Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services. Engage eligible members. Oversee the provision of ECM services and implementation of the care plan. Offer services where the member lives seeks care, or finds care most easily accessible and within SCHARP guidelines. Conduct a comprehensive assessment of each client, including demographic information, psychosocial history, and SDoH status. Connect members to other social services and supports the member may need, including transportation. Advocate on behalf of members with health care professionals. Use motivational interviewing, trauma-informed care, and harm-reduction approaches. Coordinate with hospital staff on discharge plans. Accompany members to office visits, as needed and according to SCHARP guidelines. Monitor treatment adherence (including medication). Provide health promotion and self-management training. Perform administrative duties, such as assisting in developing reports, building and maintaining a contact network of agencies and local community members, and performing other duties as assigned. Meets weekly with ECM Director and Clinical Supervisor to ensure timely completion of referral intakes, assessments, and reassessments for all enrollees and candidates for enrollment, ensuring completeness by coordinating with multidisciplinary team members. Engages ECM Model strategies to ensure member access to comprehensive and appropriate care to address health, mental health, vision, and/or dental problems. Connects clients with systems of care and guides them through making and following through with appointments and aftercare. Coordinating with multidisciplinary treatment teams that include case managers supports targeted case management in compliance with ECM practices, assisting individuals in sustaining recovery and gaining access to needed medical, social, legal, educational, and other services and support. Provides services with a strong behavioral health recovery orientation, cultural sensitivity, and awareness of the unique needs of the population of focus: homeless persons with co-occurring disorders transitioning from jail to the community. Ensures appropriate documentation of all services rendered. I serve as the primary point of contact for the member, the member's family, the authorized representative (AR), the caregiver, other authorized support person(s) as appropriate, and the multidisciplinary care team providing care to the member. • Traveling locally and out of state may be required to participate in conferences, workshops, and training. • Attend ongoing training as appropriate.

REQUIREMENTS

Must pass California State Department of Justice criminal background investigation, Live Scan, and/or fingerprinting. Must complete Training in Person Centered Planning during the first three months of employment

EDUCATION

Must have a Bachelor's degree (B.A.) in social services or a related field, with at least 2 years of experience working with children and/or families (i.e., foster children, children with DCFS involvement, juvenile justice-involved, etc.). Or Registered Nurse, LVN, or Behavioral Health or Social Services paraprofessional with at least 2 years of case management or related experience in the field and a Bachelor's degree. Bilingual Spanish is required (verbal and written skillset). Lived experience

EXPERIENCE

Must have at least one year of experience working with behavioral health populations, including homeless persons with co-occurring disorders. Must be experienced working with low-income, diverse populations, including persons affected by mental illness, substance use, and incarceration. Must have experience with and comfort working with CalAIM populations of focus (individuals experiencing homelessness, individuals with SMI/SUD, individuals transitioning from incarceration, Foster Care, and individuals with complex medical needs).

SPECIAL SKILLS AND KNOWLEDGE

Ability to effectively respond to the needs of individuals with severe impairments in their ability to function in the community. Using the agency's electronic health record requires sufficient computer skills and literacy. The user must be able to log on, type, use a mouse, and negotiate through various screens or windows to review daily chart documentation. Ability to work as a team member, facilitate and lead teams, and work with other agencies, community resources, and member's families. Must have a valid California Driver's license and the availability of a car with adequate insurance.