The Care Coordinator/Lead Care Manager works in collaboration and continuous partnership with chronically ill or “high-risk” members and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:

·Coordinate with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services.

·Engage eligible members.

·Oversee provision of ECM services and implementation of the care plan.

·Offer services where the member lives, seeks care, or finds most easily accessible and within the Plan guidelines.

·Connect member 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 member to office visits, as needed and according to the Plan guidelines.

·Monitor treatment adherence (including medication).

·Provide health promotion and self-management training

·Promote timely access to appropriate care

·Increase utilization of preventative care

·Reduce emergency room utilization and hospital readmissions

·Increase comprehension through culturally and linguistically appropriate education

·Create and promote adherence to a care plan, developed in coordination with the member, primary care provider, and family/caregiver(s)

·Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals

·Increase members’ ability for self-management and shared decision-making

·Connect members to relevant community resources to enhance member health and well-being, increase member satisfaction, and reduce health care costs.

·Connect and follow up with members, family/caregiver(s), providers, and community resources via face-to-face, secure email, phone calls, text messages, and other communications.

·Serve as the contact point, advocate, and informational resource for members, care team, family/caregiver(s), payers, and community resources

·Work with members to plan and monitor care

·Assess member’s unmet health and social needs

·Develop a care plan with the member, family/caregiver(s), and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)

·Monitor adherence to care plans, evaluate effectiveness, monitor member progress on time, and facilitate changes as needed

·Create ongoing processes for members and family/caregiver(s) to determine and request the level of care coordination support they desire at any given time.

·Facilitate member access to appropriate medical and specialty providers

·Educate members and family/caregiver(s) about relevant community resources

·Facilitate and attend meetings between members, family/caregiver(s), care team, payers, and community resources, as needed

·Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals

·Assist with the identification of “high-risk” members (the chronically ill and those with special health care needs), and add these to the member registry (or flag in EHR)

·Attend all Lead Care Manager training courses/webinars and meetings

·Provide feedback for the improvement of the ECM Program

·Offer services where the Member lives, seeks care, or finds most easily accessible and within Medi-Cal Managed Care health plans (MCP) guidelines

·Engage eligible Members

·Arrange transportation

·Call Member to facilitate Member visit with the ECM Lead Care Manager

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below represent the required knowledge, skill, and/or ability. Reasonable accommodations may enable individuals with disabilities to perform essential functions.

EDUCATION AND/OR EXPERIENCE:

· High school Diploma, Paraprofessional (with appropriate training) 

·Evidence of essential communication, education, and counseling skills

·Proficiency in communication technologies (email, cell phone, etc.)

·Highly organized with the ability to keep accurate notes and records

·Experience with health IT systems and reports is desirable

·local knowledge about and connections to community health care and

·social welfare resources are desirable

·Ability to speak a relevant second language is desirable

SKILL AND KNOWLEDGE REQUIREMENTS:

• Excellent analytical, problem-solving, and prioritization skills.
• Use statistical and graphic displays.
• Excellent verbal and written communication skills.
• High-level interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and diverse teams that may include employees, customers, and physicians.
• Effective computer skills, particularly Microsoft Office, Excel, PowerPoint, Publisher, Paint, Word, etc.
• Work independently to complete assigned tasks.
• Team building
• Project Management
• Change Management
• Quality and Process improvement tools
• Project Execution