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Description:

Job Description:

The Enhanced Care Management (ECM) Case Manager addresses the clinical and non-clinical needs of high cost and/or high-need members through systematic coordination of service and comprehensive care management that is community-based, interdisciplinary, high-touch, and person-centered. The ECM case managers work, primarily through in-person, with ECM members, adults and children, that have chronic health conditions, homelessness or at-risk, high hospital admissions, substance abuse, behavioral needs, and/or transitioning from incarceration. Using excellent communication skills, case managers will provide services and coordination to members to ensure continuity of care across health and social service programs as well as community based and long term-support service programs. This position requires strong interpersonal and organizational skills to build rapport with members and to coordinate referrals and care amongst various healthcare providers and community services. The ECM case manager also works with the member’s interdisciplinary team in supporting the member. The case manager engages member and member support systems to define priorities that are central to the member’s desired needs and goals.

Requirements:

Essential Duties and Functions:

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Additional Key Responsibilities

• Complete daily member outreach calls and follow-up calls to meet established productivity and outreach targets.
• Make outbound phone calls to engage members, schedule appointments, provide education, coordinate services, and support care plan goals.
• Assist the ECM team in achieving monthly outreach, engagement, and enrollment targets by maintaining consistent call volumes and timely follow-up.
• Accurately document all phone calls, member interactions, and care coordination activities in the electronic health record (EHR) on the same day of service.
• Assist with additional administrative and care coordination tasks as assigned to support department goals and member care.

Teach and assist members to better manage their chronic diseases using realistic and SMART (specific, measurable, attainable, realistic, and timely) goals

· Provide as-needed teaching to members during medical appointments to assist in the understanding of disease knowledge, medication compliance, specialty services recommended by provider and/or any other medical needs the members may require assistance in understanding

· Assist members and their families in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance)

· Conducts home visits or meets clients in community-based locations to engage and assist with ECM related services

· Use a step-by-step process when teaching skills

· Use positive reinforcement and encouragement

· Use a flexible approach with a diverse population

· Attend both mandatory in-service trainings and related conferences to support a fundamental and expanded knowledge of Enhanced Care Management services and strategies to meet quality outcomes for ECM goals

· Advocate on behalf of the members as needed, with the medical, behavioral, substance abuse, and treatment teams

· May assume advocate role on the member’s behalf to ensure approval of the necessary supplies/services for the patient in a timely fashion

· Manage own caseload while providing monthly care to all members as needed and reducing barriers to care

· Provided community-based resources to members

· Enroll and dis-enroll members into and out of ECM program

· Completing Comprehensive Assessment

· Promoting health and working with members regarding provider’s health plan

· Take lead with inter-disciplinary team (ICT) to complete needed program requirements

· Complete documentation of encounters-notes for all care coordination services on member’s EHR

· Utilizes computer for detailed data entry in multiple applications including Microsoft Office and Excel

· Follow-up with member’s missed appointments and referrals

· Follow-up with hospital/Urgent care discharges

· Collaborate with ECM providers including physicians and nurse practitioners

· Using motivational interviewing skills to engage and help members and their support system.

· Scheduling, appointment reminders, and coordination of transportation

· Assist with ECM Outreach: contacting ECM eligible members to initiate services

· Complete required interagency and other necessary paperwork

· Maintain confidentiality in accordance with clinic policies and HIPPA regulations

· Follow required office procedures in a cooperative manner.

· Treat members with respect

· Work in cooperation with co-workers and supervisory staff