SUMMARY:
The Lead Care Manager (LCM) is responsible for helping patients and their families to navigate and access community services, other resources and adopt healthy behaviors. Under the direct supervision of the Enhanced Care Management Program Manager / Director, the Lead Care Manager will be evaluated based on skillset, experience, and ability to provide program services under the capacity as a Lead Care Manager (LCM) to a caseload of adult beneficiaries and/or youth populations of focus (PoF). LCM is a trusted member of and/ or a person who has an unusually close understanding of the community served in the delivery of health-related services through either working directly with providers or their partner organizations. This trusting relationship with the community enables LCMs to serve as a liaison between health and social services and the community to facilitate members' access to community services and improve the quality and cultural competence of services delivered. LCMs build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.
ESSENTIAL FUNCTIONS:
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Provides information and referrals to community resources necessary to improve health or address health-related social needs. Including, but not limited to, food and nutrition, housing security, economic support, and legal services.
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Reports on program implementation, data of individuals receiving assistance, and client stories sharing highlights, challenges, and recommendations.
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Provides ongoing support and services for clients as needed.
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Performs other job duties as required by the Manager and or Director.
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Engage, motivate, and advocate community members to build knowledge and skills for self- directed change and community development, build rapport with clients who may have no other support network
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Conduct assessments, build care plans with clients, meet routinely to achieve goals, and all other supportive services as needed.
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Assesses member's needs in mental health, behavioral health, physical health, substance abuse, financial stability, employment, food security, clothing, housing, and other needs.
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Provide onsite case management services in the areas of independent living skills, cooking groups, house meetings, social events, employment linkage, benefits establishment, and other services as needed to assist in reaching case plan and treatment goals.
- Attend multi-discipline coordination meetings to discuss case progress, and barriers, and receive guidance from health professionals
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Accompany members to appointments as needed.
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Builds and maintains collaborative and positive relationships with community, clinic staff, and clinic partners.
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Provides education to individuals or groups on topics related to health and health promotion.
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Provides information and referrals to community resources necessary to improve health or address health-related social needs. Including, but not limited to, food and nutrition, housing security, economic support, and legal services.
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Assists and/or navigating patients in accessing health-related services and community resources, such as appointments and assistance with enrollment forms.
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Collects data and information as required by the evaluation plan and processes. Provides feedback to evaluation team and program management on evaluation process issues.
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Uses assigned technology to complete job functions effectively.
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Maintain and document confidential information
OTHER RESPONSIBILITIES:
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All other duties as required and assigned.
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Flexible with varying hours based on the needs of the department.
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Good written and verbal communication skills required for contacts.
Within other departments, patients, families, the community, and medical staff
SUPERVISORY RESPONSIBILITIES: None
EDUCATION, KNOWLEDGE, SKILLS, ABILITIES, AND EXPERIENCE:
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Education: high school graduate or equivalent required. Medical Assistant Certification preferred
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Strong project leadership skills with goal orientation. Able to work with professional and technical staff to manage large projects and change activities with minimal business interruption and on-time delivery.
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Experience in community work, education, health care, or related field preferred
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Advance understanding of hospital operations and clinical functions.
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Knowledge in Cultural Diversity
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Experience in community work, education, health care, or related field preferred
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Strong project leadership and implementation skills.
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Strong analytical skills, able to translate concepts into implementation strategies.
Advance understanding of interfaces
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Mature understanding of clinical application support processes and ambulatory EHR workflows
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A flexible and positive attitude
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A welcoming and nurturing attitude toward our patient population
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Strong computer skills and basic knowledge of Microsoft Excel
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Experience in customer service setting
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Strong verbal and written communication
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High level of integrity
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Proficient PC skill
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Fluency in Spanish preferred.
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E-Clinical Works Experience preferred
LICENSES AND CERTIFICATIONS:
Basic Life Support
Community Health Worker Certification is preferred or willingness to become certified according to state requirements.
AGE OF POPULATION SERVED:
Newborn Infant/Pediatric Adolescent Adult Geriatric All X No Patient Care
PHYSICAL REQUIREMENTS:
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Occasional travel between training locations required.
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Travel within the communities required
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Sitting for extended periods of time
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Stooping and bending are required.
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Dexterity of hands and fingers to operate a computer keyboard, mouse, power tools, and to handle other computer components.
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Some lifting of more than 50 lbs. may be required.
