Lead Care Manager

ACHC is a Federally Qualified Health Center and licensed primary care clinic. We provide medical and dental care, with additional specialists in Chiropractic, Internal Medicine, Neurology, Gynecology, Pediatrics, Psychology, Podiatry and Optometry. ACHC Clinics are located across Fresno, Kings and Tulare counties.

RESPONSIBILITES

Assists ECM Manager and provides care coordination support to the Aria Community Health Center (ACHC) Enhanced Care Management Program to patients residing in Tulare, Fresno and Kings County. This position is pivotal in ensuring all needs of the patient needed to improve health outcomes are coordinated both within the organization as well with outside providers. The needs of the patient may include complex health conditions, mental health diagnosis, shelter concerns, financial instability, extreme poverty, transportation, or food insecurity. The Lead Care Manager provides initial outreach to potential eligible patients and works with the eligible patients and care coordinators to meet established goals while using patient centered methodologies. Understanding of motivational interviewing, trauma informed care, and persuasion skills is fundamental to meeting the objectives of the program.

ESSENTIAL JOB FUNCTIONS & RESPONSIBILITIES

• Meet with patients in their homes and/or attend doctor visits to assist the patient with meeting health outcome goals.
• Carries a caseload.
• Advocate for patient in various settings including internal Multi-Disciplinary Team meetings, Insurance carriers, outside health providers, social workers, resource providers, etc.
• Connect patients to needed services that will reduce barriers that impact their health including shelter, transportation, food access, in home care, etc.
• Use motivational interviewing and trauma-informed care practices to ensure patients meet the goals established by Clinical Team.
• Engage with patients that meet program eligibility requirements.
• Provide health promotion and self-management training to individual patients and their families.
• Conducts regular telephonic outreach and follow-up with ECM Patients.
• Complete comprehensive Intake assessments.
• Participate in various meetings, internally and externally.
• Submit medical claims needed for program reimbursement including necessary documentation to support claims and actions in the company EHR system.
• Complete enrollment screening and documentation, and Health Action Plan reports, among other necessary reports.
• Verbally present patient case to Multi-Disciplinary Team.
• Distribute health promotion materials.
• Responsible for accurate and timely documentation which includes but is not limited to program enrollment, assessment, updated activity/progress notes, resource access applications, releases of information, and any other forms necessary to document services.
• Supports other ECM Care Team members with delegated tasks.
• Ensures the privacy and security of Protected Health Information (PHI) as outlined in the policies and procedures relating to HIPPA compliance.
• Other duties as assigned, including, but not limited to verification of insurance eligibilities, submission of treatment authorizations, and other duties as assigned.

Education:

• Preferred: Associate degree in Health Sciences or Human Services, or in a closely related field.

Experience:

• 1-year experience within a clinic or healthcare setting.
• Required: Bilingual English/Spanish
• Preferred: Lived experience with a chronic health condition

May substitute one year experience for any of the following Certificates/Licenses: Nursing Assistant, Medical Assistant or Home Health Aide.
 

Skills / Ability:

• Basic understanding of best practices and/or lifestyle recommendations in common complex conditions including asthma, depression, diabetes, and heart conditions including hypertension.
• Basic understanding of various government and non-profit resources including public assistance, rent/utility assistance, food distribution, etc. Experience with County resources is preferred.
• Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.
• Exercise appropriate judgment and decision making.
• Communication skills including interpersonal, verbal, and writing. Knowledge and experience in motivational interviewing is preferred.
• Able to sufficiently engage members and providers on the phone and in person.
• Organization skills including prioritizing tasks and time management.
• Highly skilled interpersonally, with excellent teamwork and relationship skills.
• Ability to work well under pressure with experience in establishing priorities, meeting deadlines, and adapting quickly to change.
• Ability to independently seek out resources as well as work collaboratively in solving barriers to care.
• Ability to read, understand and follow oral and written instructions including internal policies and communications as well as applicable local, State, and Federal regulations.
• Proficient with various software systems including Microsoft Office Suite, Electronic Health Record (EHR) programs, and Payroll programs.
• Demonstrates ability to work in a regulatory climate that includes oversight by State and Federal entities, payer contracts, etc.
• Possess a genuine respect for others and acceptance of their individual, social, and cultural traits. Experience working with traditionally marginalized populations is preferred.
• Requires the ability to drive to patient residences or healthcare facilities based on scheduling and care needs.
• Able to travel and attend professional meetings, conferences, trainings, and clinic sites.

Other Requirements:

• Required: Valid driver’s license and proof of car insurance are required.
• Required: Pass background check for Federally funded programs.

Physical/Cognitive Requirements:

• Hearing: Adequate to perform job duties in person and over the telephone.
• Speaking: Must be able to communicate clearly in person and over the telephone.
• Vision: Visual acuity adequate to perform job duties, including reading information from printed sources and computer screens.  
• Cognitive: Aptitude to complete tasks, including abilities such as learning, remembering, focusing, categorizing, and integrating information for decision making, problem-solving, and comprehending.      
• Other: Requires occasional lifting and carrying items weighing up to 20 pounds unassisted. Requires frequent bending, reaching, and repetitive hand movements (specifically keyboarding and writing), standing, walking, squatting and sitting, with some lifting, pushing and pulling exerted regularly throughout a regular work shift.

NOTE: The essential job functions for this position include but may not be limited to those listed in this job description. Employees hired for this position must be able to perform the essential functions of this job without imposing significant risk of substantial harm to the health or safety of themselves or others.

BENEFITS

• 403(B)
• 403(B) matching
• Medical Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• Paid Holidays
• Vacation Pay
• Sick Pay

Aria Community Health Center participates in E-Verify.

Aria Community Health Center is an equal opportunity employer and does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.