Lead Care Manager

Lead Care Manager Dr. Riba's Health Club - 4.5 Santa Ana, CA Job Details Full-time $30 - $35 an hour 2 hours ago Benefits Health insurance Dental insurance 401(k) Paid time off Vision insurance Qualifications Spanish Teamwork Electronic health records (EHR) management Master's degree Driver's License Bachelor's degree Clinical documentation Computer skills

Full Job Description Role Overview:

The Lead Care Manager (LCM) is a pivotal role in Enhanced Care Management (ECM), focusing on interdisciplinary, high-touch, and client-centered care coordination. The LCM is the primary member of a client's care team who delivers ECM services, facilitating the initial comprehensive assessment, care plan development and service implementation. This role involves proactive engagement across community referrals, providers and resources, utilizing evidence-based practices to address social determinants of health and barriers to service access. Under the supervision of the Supervising ECM Case Manager, the employee will provide ECM program services to a caseload of adult and/or youth populations of focus (POF). Adult POFs include unhoused individuals, high utilization of emergency departments/hospitals, and those experiencing serious mental health or substance use needs. Youth POFs include unhoused youth or families, high utilization of emergency departments/hospitals, those experiencing serious mental health or substance use needs, those involved in the foster care system, and those facing birth equity disparities.

Key Responsibilities:

• Provide care coordination, health promotion, comprehensive transitional care, coordination of and referral to community and social support services, benefit establishment.
• Complete the comprehensive assessment with each enrolled client, in order to identify their primary needs, strengths, barriers, goals and appropriate wrap around services. Regularly assesses members needs in behavioral health, physical health, financial stability, employment, food security, clothing, housing and other needs.
• Develop and implement personalized care management plans for each client based on the information gathered during the assessment process. Identify key members of the client's care team.
• Coordinate the work of the identified care team to ensure implementation of the care plan. Facilitates multidisciplinary team conference meetings as needed.
• Overcome barriers to treatment and medication management, ensuring access to necessary health, behavioral, and social services for clinical and non-clinical care needs.
• Monitor treatment adherence and support clients in achieving their health and wellness goals using a person-centered approach.
• Assist in coordinating and tracking transitional care services when a change in setting or status occurs, including discharge planning and post-acute follow-ups.
• Engage in active collaboration with healthcare providers and establish supportive familial systems for clients.
• Maintain meticulous documentation of engagements, comprehensive assessments, care plans, and service referrals in the Electronic Health Record (EHR) system.
• Maintain timely, accurate, and HIPAA-compliant documentation in the organization's care management or EHR system.

Expectations:

• Strong understanding of ECM principles, with a focus on ethical client engagement and safety.
• Ability to manage a team of care providers to ensure each client is provided with the highest quality care management.
• Effective collaboration and coordination with the Outreach and Engagement Specialist, Intake Specialist, Peer Support Specialists/Community Health Workers, external providers and organizations, and other relevant parties.
• Utilization of trauma informed care, motivational interviewing, and other best practices when engaging with clients.
• Proficient use of the EHR system and familiarity with various healthcare services.
• Proficiency in documentation and data management with an understanding of HIPAA guidelines and ensure compliance with federal, state, and company policies.
• Utilization of techniques proven to increase engagement with identified focus populations.
• Utilization of motivational interviewing, harm reduction and trauma-informed approaches
• Commitment to cultural sensitivity and diverse community engagement.

Core Competencies:

• Advanced knowledge of trauma-informed care, harm-reduction, and motivational interviewing
• Clinical judgment and critical thinking in community-based settings
• Skilled in crisis intervention and de-escalation to address emergent situations such as risk of harm to self/others and other behavioral/social factors (i.e. domestic violence).
• Skilled in navigating complex care systems, including Medi-Cal and community resources
• Leadership in interdisciplinary team collaboration
• Strong written and verbal communication skills
• Cultural humility and the ability to engage with diverse populations respectfully and effectively
• Detail-oriented, organized, and accountable for documentation and reporting.

Minimum Requirements:

• BA in social work, psychology, or related field + minimum of 2 years relevant experience. Or AA in social work, psychology, or related field + 3 years experience in mental health field and/or case management experience.
• Proficient computer skills and experience using EHR systems.
• Valid CA Driver's License, maintain a good safety record (verified by DMV at hire and periodically) and a reliable vehicle; proof of liability insurance if driving a personal vehicle.
• Able to multi-task in a fast-paced environment, apply professional judgement in solving difficult issues, and to communicate in a clear, precise, and professional manner.

Preferred Qualifications:

• Master in Social Work
• Prior experience working with ECM Populations of Focus (e.g., individuals experiencing homelessness, serious mental illness, substance use disorder, foster care, pregnancy/postpartum, or complex medical needs).
• Bilingual (Spanish or Vietnamese) or multilingual capacity.
• Familiarity with Medi-Cal and CalAIM initiatives, ECM documentation, and quality improvement processes.
• First Aid and CPR certifications.

Working Conditions:

• This role may require a combination of office work, field visits, and, in some cases, remote work.
• Physical demands may include sitting or walking for long periods and, occasionally, lifting up to 20 pounds (adjust as needed).

onments.

Pay:

$30.00 - $35.00 per hour

Benefits:

401(k) Dental insurance Health insurance Paid time off Vision insurance

Work Location:

Hybrid remote in Santa Ana, CA 92707