Under the direct supervision of the Enhanced Care Management Director, the Enhanced Care Management Lead Care Manager is responsible for coordinating and implementing organization-wide Enhanced Care Management. Oversees and implements provision of the Enhanced Care Management (ECM) services; and identification and achievement of Care Plan goals and objectives with the member that meet their self-identified strengths and health care and psychosocial needs. 

DUTIES AND RESPONSIBILITIES:

• Engages eligible ECM members
• Offers services where the ECM member lives, seeks care, or finds most easily accessible and within health plan guidelines
• Oversee provision of ECM services and implementation of the Care Plan
• Connects with ECM member via phone or in-person to facilitate engagement, assessment, follow-up, and education/training visits in order to develop and address the Care Plan.
• Works in conjunction with ECM member to identify Care Plan goals and objectives.
• Connects ECM member to other ILOS / social services and supports he/she may need.
• Accompanies ECM member to office visits, as needed and according to health plan guidelines.
• Arranges transportation.
• Responsible to convene care conference meetings.
• Coordinates with ECM resource partners to obtain data/information to ensure accurate Care Plan updates.
• Utilize AVFHC’s NextGen and other electronic tracking systems to coordinate services and input data for reporting.
• Attends required ECM trainings.
• Facilitates internal ECM trainings/updates to AVFHC clinical and administrative staff members.
• Collaborates with AVFHC IT department to ensure ECM templates are appropriate and effective at capturing needed data/information.
• Reviews existing AVFHC protocols and polices to match ECM requirements.
• Develops new ECM protocols, policies, and accompanying workflows.
• Assists the required ECM reports and other internal reports.
• Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the Member and non-duplication of services
• 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 plan
• Accompany Member to office visits, as needed and according to Arroyo Vista and MCP guidelines
• Monitor treatment adherence (including medication)
• Provide health promotion and self- management training
• Other duties as assigned.

REQUIREMENTS:

• Registered Nurse, LVN or Behavioral Health or Social Services paraprofessional with at least 2 years of case management or related experience in the field.
• BA in social work, sociology, human services or related fields preferred
• 3-5 years of experience providing home health and/or social services case management services to low income populations with one or more of the following: complex chronic conditions, high utilizer of emergency room and tertiary health care services, severe mental illness, and/or homelessness.
• Bilingual in English/Spanish (oral and written)