The Enhanced Care Management (ECM) Lead Care Manager is responsible for coordinating all covered medical and non-medical supportive services the member needs including physical, behavioral, dental, developmental, oral health, long term services and supports (LTSS), Specialty Mental Health Services, Drug Medi-Cal/Drug Medi-Cal Organized Delivery System services any Community Supports and other services that address social determinants of health (SDOH) needs, regardless of setting. The ECM Lead Care Manager will work closely with the CalAIM Community Supports Program staff to provide team-based, patient-centered care management for homeless and at-risk of homelessness patients. This position reports directly to the ECM Supervisor and works closely with the Housing Solutions Manager and Director.

Qualifications/Skills and abilities:

• Bachelor’s Degree, Social Work (or related field) with experience working in chemical health, mental health, co-occurring disorders are preferred. Persons with less than a BA/BS degree but with at least 2 years of direct life experience working with long-term homeless, low income, and diverse populations and have a working knowledge of mental health and additions issues are welcome to apply.
• Excellent verbal and written communication skills and the ability to work independently.
• Knowledge of how to use Microsoft programs and computer literacy are required.
• Preferred skills related to outreach and engagement, care planning, care coordination, health promotion, transitional care support, member and family education, and social services coordination.
• Preferred minimum of 1 year of experience in care coordination and case management for the following populations: Individuals/ Families experiencing homelessness, Individuals at risk for avoidable hospital stay (High Utilizers), Individuals w/Serious Mental Health and or SUD, Adult Nursing Facility Residents Transitioning to the Community, Adults w/intellectual or developmental disabilities.
• Preferred experience with HMIS Data Entry /CalOptima Health strongly preferred.
• Preferred experience with Housing First and Harm-Reduction strategies, and Motivational Interviewing, Patient Centered and Trauma Informed Care, Crisis Intervention & Prevention strategies.
• Preferred experience in engaging and assisting individuals/families with acute mental illness & substance use to access/navigate health care as well as other needed services.
• A valid CA driver’s license, proof of insurance and a reliable vehicle is required. Comfortable with utilizing your own vehicle to conduct home visits, visit clients at shelters, meeting clients out in the community etc.
• Office Hours are 8:30am-5pm; Monday-Friday. Will include some weekends, late evening work and the ability to respond to crisis situations as necessary.

DUTIES AND RESPONSIBILITIES:

Client/Service Delivery

• Maintain a minimum caseload of 17-25 individuals. Meet with members as needed to complete Health Needs Assessments, Care plans which include short and long-term measurable goals.
• Engage, outreach, and enroll eligible ECM members in services and help address barriers.
• Offer services where the member lives, seeks care, or finds most easily accessible and within CalOptima Health guidelines.
• Support and engage members in their treatment including coordination for medication review and/or reconciliation, scheduling appointments, providing appointments reminders, coordinating transportation when needed for all/any medical appointments, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment. Accompany members on office visits as needed and according to CalOptima Health guidelines.
• Advocate on behalf of the member with health care professionals and work with hospital staff on discharge plans
• Collaborate with area hospitals, behavioral health providers, specialists, dental providers, providers of services for Long-Term Services of Support (LTSS) and other associated entities such as Community Supports as appropriate to coordinate member care.
• Use motivational interviewing and trauma informed care practices.
• Monitor treatment adherence (including medication)
• Provide health promotion and self‐management training to enrolled ECM members.
• Report ECM patient progress, concerns and needs to multi-disciplinary team to improve patient care.
• Other duties may be assigned or may be modified.

Team/Staff Relations:

• Work as a Mercy House team member with all staff and volunteers to implement the mission and core values of the agency.
• Attend regular internal and external agency meetings.
• Work as part of a team to plan and develop resident programs.
• Work in a team environment, fast passed environment, be flexible, be able to adapt to sudden changes, be trustworthy, be reliable, be empathetic.
• Communicate effectively with diverse populations.

Administrative:

• Keep accurate, up to date documentation on all clients, including but not limited Health Needs Assessments and Care Plans
• Assist with all data collection systems.
• Assure deadlines are met.
• Utilize computers and appropriate software (eg. Microsoft: Word, Outlook, Excel, PowerPoint) and/ or specific systems applicable to position.
• Responding to calls and emails in a timely manner.
• Perform tasks independently and prioritize workload.
• Physical requirements: Occasional lifting of items up to 25 lbs. (i.e., accepting donated items)
• Prolonged periods sitting at a desk and working on a computer.
• Other duties or projects as assigned.

Knowledge of:

• Confidentiality and the legal and ethical issues pertaining to case management.
• Effective documentation and guidelines.

Job Type: Full-time

Pay: $21.00 - $22.00 per hour

Expected hours: 40 per week

Benefits:

• 403(b)
• 403(b) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Paid time off
• Referral program
• Vision insurance

Schedule:

• Monday to Friday

Work setting:

• In-person
• Office

Application Question(s):

• Are you related to or know current/former employees of Mercy House?

Education:

• Bachelor's (Preferred)

Experience:

• Case management: 1 year (Preferred)
• HMIS: 1 year (Preferred)

License/Certification:

• CA Driver's license, proof of insurance and reliable vehicle (Required)

Work Location: In person