GENERAL PURPOSE:
Under the general supervision of the Enhanced Care Coordination Program Manager, the Lead Case Manager is responsible for providing coordinated care for patients. Implements and supervises the development, monitoring, and evaluation of interdisciplinary care. The Case Manager is responsible for coordinating 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 enhanced care management (ECM) services and implementation of the care plan. The Lead Case Manager offers services where the member lives, seeks care, or finds most easily accessible and connects member to medical care and other social services the member may need. This individual advocates on behalf of members with health care professionals, uses motivational interviewing, trauma-informed care, and harm-reduction approaches, coordinates with hospital staff on discharge plan, accompanies member to office visits as needed and according to the plan guidelines, monitor treatment adherence (including medication), and provides health promotion and self-management training.
MAIN RESPONSIBILITIES AND DUTIES:
1) Conducts daily outreach to assigned panel of patients within geographical areas that are reasonable and easily accessible.
2) Actively enrolls all eligible patients into the California Advancing and Innovating Medi-Cal (CalAIM) program.
3) Secures patient discharge instructions and uploads to patient chart.
4) Uses the Ideal Transitions of Care Framework for coordinating care for high-risk patients (Table 1).
5) Provides medication adherence support through facilitation, patient education, and service linkages.
6) Conducts comprehensive patient assessments.
7) Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
8) Assists patients in establishing and achieving care and treatment goals through a documented care plan.
9) Coordinates with Ampla Health primary care and other departments to achieve patient centered care and optimize patient communication and care.
10) Coordinates care with other organizations and other services as needed.
11) Assists with referring patients to the Chronic Care Management Program when needed.
12) Maintains an accurate record of outreach, communications, patient needs, and services.
13) Works to achieve “transition of care” program metrics as detailed to Table 1, below.
14) Supports Ampla Health’s mission by providing superior customer service and respecting patients.
15) Strengthens clinical and quality teamwork and rapport through strong work ethic and individual accountability.
16) Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
17) Treats patients with empathy and respect and conduct oneself professionally.
18) Complies with organizational guidelines and health care laws and regulations.
19) Other duties as assigned by supervisor.
TABLE 1: AMPLA HEALTH TRANSITIONS OF CARE PROGRAM METRICS
Patients will be contacted within 12 hours of discharge
Ensure that 80% of all patients that had an ER or Hospital visit assigned to Ampla Health were contacted at least once via phone, email, or patient portal to schedule their follow-up appt with their PCP 12 hours after discharge (or Ampla Health notification of discharge).
Increase Post Hospital Discharge Follow-up
Ensure that 50% of patents that had an ED visit had a follow-up visit scheduled with their PCP within 3-7 days of the ED visit (or Ampla Health notification of discharge).
Member Engagement: Kept vs. Missed Appts
Ensure that 75% of scheduled Care Coordination appts (ER/follow-up) were kept.
Member Enrollment into Transitions of Care Program
Increase the total number of patients (who had an ER or Hospital visit) enrolled into the Transitions of Care program to 50%
Medication Adherence
All patients asked if they have and are taking discharge medications as prescribed.
QUALITIES & CHARACTERISTICS
1) Maintains a professional relationship and positives attitude with co-workers, the public, patients and all Ampla Health’s staff, Board of Directors, and vendors.
2) Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through their actions.
3) Strives to learn more and is receptive to learning different ways of doing things.
4) Displays enthusiasm toward the work and the mission of Ampla Health
5) Ability to work in a fast-paced, patient service-oriented environment.
PROFESSIONAL KNOWLEDGE, SKILLS & ABILITIES:
1) High School Diploma
2) Certified Medical Assistant preferred
3) Current CPR Certification
4) Valid California driver’s license and proof of insurance.
5) Strong problem solver
6) Possesses outstanding interpersonal skills, including excellent written and verbal skills.
7) Ability to connect and engage patients in person and over the phone.
8) Demonstrates ability to promote quality improvement through development and maintenance of standards.
9) Sensitive to the needs of the cultures represented in the Ampla Health patient population.
10) Demonstrates clear knowledge of Ampla Health’s clinic structure, standards, procedures, and protocols.
COMMUNICATIONS SKILLS:
1) Must have neat and legible handwriting.
2) Must be able to interact with patients courteously and calmly.
3) Ability to communicate well with the public.
WORKING CONDITIONS & PHYSICAL REQUIREMENTS:
Works will with patients in a generally comfortable environment office. Employees must possess the following physical requirements:
-
Must be in good health and able to lift up to 40 lbs.
-
Must be able to hear staff on the telephone and those who are served in person, and speak clearly to communicate information to clients and staff.
-
Ability to operate standard office equipment such as a computer, telephone, fax machine, copier, etc.
-
Must be able to reach above the shoulder level to work, bend, squat and sit, stand, stoop, crouch, reach, kneel, twist and turning.
GENERAL PURPOSE:
Under the general supervision of the Enhanced Care Coordination Program Manager, the Lead Case Manager is responsible for providing coordinated care for patients. Implements and supervises the development, monitoring, and evaluation of interdisciplinary care. The Case Manager is responsible for coordinating 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 enhanced care management (ECM) services and implementation of the care plan. The Lead Case Manager offers services where the member lives, seeks care, or finds most easily accessible and connects member to medical care and other social services the member may need. This individual advocates on behalf of members with health care professionals, uses motivational interviewing, trauma-informed care, and harm-reduction approaches, coordinates with hospital staff on discharge plan, accompanies member to office visits as needed and according to the plan guidelines, monitor treatment adherence (including medication), and provides health promotion and self-management training.
MAIN RESPONSIBILITIES AND DUTIES:
1) Conducts daily outreach to assigned panel of patients within geographical areas that are reasonable and easily accessible.
2) Actively enrolls all eligible patients into the California Advancing and Innovating Medi-Cal (CalAIM) program.
3) Secures patient discharge instructions and uploads to patient chart.
4) Uses the Ideal Transitions of Care Framework for coordinating care for high-risk patients (Table 1).
5) Provides medication adherence support through facilitation, patient education, and service linkages.
6) Conducts comprehensive patient assessments.
7) Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
8) Assists patients in establishing and achieving care and treatment goals through a documented care plan.
9) Coordinates with Ampla Health primary care and other departments to achieve patient centered care and optimize patient communication and care.
10) Coordinates care with other organizations and other services as needed.
11) Assists with referring patients to the Chronic Care Management Program when needed.
12) Maintains an accurate record of outreach, communications, patient needs, and services.
13) Works to achieve “transition of care” program metrics as detailed to Table 1, below.
14) Supports Ampla Health’s mission by providing superior customer service and respecting patients.
15) Strengthens clinical and quality teamwork and rapport through strong work ethic and individual accountability.
16) Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
17) Treats patients with empathy and respect and conduct oneself professionally.
18) Complies with organizational guidelines and health care laws and regulations.
19) Other duties as assigned by supervisor.
TABLE 1: AMPLA HEALTH TRANSITIONS OF CARE PROGRAM METRICS
Patients will be contacted within 12 hours of discharge
Ensure that 80% of all patients that had an ER or Hospital visit assigned to Ampla Health were contacted at least once via phone, email, or patient portal to schedule their follow-up appt with their PCP 12 hours after discharge (or Ampla Health notification of discharge).
Increase Post Hospital Discharge Follow-up
Ensure that 50% of patents that had an ED visit had a follow-up visit scheduled with their PCP within 3-7 days of the ED visit (or Ampla Health notification of discharge).
Member Engagement: Kept vs. Missed Appts
Ensure that 75% of scheduled Care Coordination appts (ER/follow-up) were kept.
Member Enrollment into Transitions of Care Program
Increase the total number of patients (who had an ER or Hospital visit) enrolled into the Transitions of Care program to 50%
Medication Adherence
All patients asked if they have and are taking discharge medications as prescribed.
QUALITIES & CHARACTERISTICS
1) Maintains a professional relationship and positives attitude with co-workers, the public, patients and all Ampla Health’s staff, Board of Directors, and vendors.
2) Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through their actions.
3) Strives to learn more and is receptive to learning different ways of doing things.
4) Displays enthusiasm toward the work and the mission of Ampla Health
5) Ability to work in a fast-paced, patient service-oriented environment.
PROFESSIONAL KNOWLEDGE, SKILLS & ABILITIES:
1) High School Diploma
2) Certified Medical Assistant preferred
3) Current CPR Certification
4) Valid California driver’s license and proof of insurance.
5) Strong problem solver
6) Possesses outstanding interpersonal skills, including excellent written and verbal skills.
7) Ability to connect and engage patients in person and over the phone.
8) Demonstrates ability to promote quality improvement through development and maintenance of standards.
9) Sensitive to the needs of the cultures represented in the Ampla Health patient population.
10) Demonstrates clear knowledge of Ampla Health’s clinic structure, standards, procedures, and protocols.
COMMUNICATIONS SKILLS:
1) Must have neat and legible handwriting.
2) Must be able to interact with patients courteously and calmly.
3) Ability to communicate well with the public.
WORKING CONDITIONS & PHYSICAL REQUIREMENTS:
Works will with patients in a generally comfortable environment office. Employees must possess the following physical requirements:
-
Must be in good health and able to lift up to 40 lbs.
-
Must be able to hear staff on the telephone and those who are served in person, and speak clearly to communicate information to clients and staff.
-
Ability to operate standard office equipment such as a computer, telephone, fax machine, copier, etc.
-
Must be able to reach above the shoulder level to work, bend, squat and sit, stand, stoop, crouch, reach, kneel, twist and turning.
