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