Case Coordinator

POSITION TITLE : Lead Care Manager

Job description

The Lead Care Manager serves as the primary contact to patients enrolled in the Enhanced Care Management (ECM) Program and plays a central role connecting the care team members with the patient and with each other for optimal communication about the patient’s Care Plan.

The ultimately goal of ECM is to effectively manage the patients over the continuum of care to ensure that their medical and psychosocial needs are met for a well-managed health condition and to minimize the likelihood of preventable hospital and emergency department utilization.

ESSENTIAL DUTIES

1. Engages eligible ECM patients and offers and / or facilitates care management services where the patient lives, seeks care, or finds most easily accessible 1 .

2. Conducts comprehensive risk assessments and develops patient-centered Care Plans that includes goals based on the patients’ physical and psychosocial health needs, and considers their personal preferences.

3. Oversees effective implementation of Care Plan, ensuring initial plan is drafted with 60 days from the patient’s enrollment and that it is updated as necessary, but no less than one per quarter, thereafter.

4. Educates patients on self-management skills and / or recruits support from a caregiver / family member to support the accomplishment of the Care Plan.

5. Supports health behavior change utilizing motivational interviewing and trauma informed care practices.

6. Monitors treatment adherence.

7. Regularly initiates or participates in case conferences with providers and / or ECM Clinical Consultants.

8. Connects patient to social services, including housing, transportation, etc., as needed to achieve patient’s goals and well-managed care

9. Coordinates with hospital staff on discharge plan and with other transitional care as feasible.

10. Accompanies patient to office visits, as needed and according to health plan guidelines 2 .

11. Maintains a regular contact schedule with enrolled patients that includes at least one in-person 3 encounter per month.

12. Document care management encounters in the Electronic Health Record (EHR) with the appropriate billing codes

13. Documents outreach attempts in ECM tracking spreadsheet and i2i tracking group

14. Support the completion of ECM monthly reports for each Health Plan

15. Perform other duties as assigned.

POSITION REQUIREMENTS

1. Bachelor Degree required

2. Two years of experience in community health or social service setting required

3. Case management / care coordination experience

4. English and Spanish fluency required

5. Proficiency in Microsoft Office Suite products

6. Valid driver’s license and willing to drive to Eisner sites and communities where ECM patients live

7. Must be able to work in interdisciplinary team setting

8. Effective communication and interpersonal skills

9. Experience with Electronic Health Records preferred

10. Ability to independently seek out resources and work collaboratively

Benefits :

• PTO Accrual rate of 7.08 hours per pay period (26 pay periods per year).
• 8 Paid Holidays.
• 40 hours of paid Jury Duty time per year.
• Medical, Dental, & Vision insurance (PPO option available).
• Health Reimbursement Account.
• Flexible Spending Accounts (Healthcare, Dependent Care, & Transportation).
• Employer-Sponsored life insurance & long term disability.
• 30 covered visits for Chiropractic or Acupuncture visits.
• 401k plan

EEO STATEMENT :

Eisner Health is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Eisner Health does not discriminate on the basis of race, religion, color, sex, gender identity, gender expression, sexual orientation, age, disability, national origin, or veteran status.

Job Type : Full-time

Pay : $23.00 - $30.00 per hour