ECM Lead Care Manager

TITLE ECM Care Manager, Homeless Youth & High Utilizer Youth

REPORTS TO ECM Program Director

LOCATION Los Angeles County, CA (Hybrid)

ORGANIZATIONAL DESCRIPTION

Established in 1978, Affordable Living for the Aging (ALA) is a nonprofit organization that provides case management and affordable housing for high-acuity populations in Los Angeles.

ECM PROGRAM

Enhanced Care Management is a new, statewide benefit established by the Department of Health Care Services (DHCS) to provide a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need beneficiaries enrolled in Medi-Cal Managed Care.

The goal of the ECM program is to effectively manage the medical and psychosocial needs of these members to ensure a well-managed health condition and minimize the likelihood of preventable hospital admissions and emergency department utilization.

JOB SUMMARY

The Care Manager will serve as the point of contact enrolled members, which include high acuity members experiencing homelessness, mental illness, substance use disoders, or are high utilizers of the emergency system.

The LCM will also be the point person for any Homeless and High Utilizer Youth enrolled in the program. The Care Manager is responsible for assessments, development of care plans, and ongoing service delivery to ensure members are able to manage their chronic or complex health conditions.

The Care Manager will support all identified health, behavioral and social needs of enrolled members.

RESPONSIBILITIES

• Provides care management services to enrolled members with a caseload up to 50 members to assist them in managing their complex or chronic health conditions.
• Provide Assessments and Care Plans for newly enrolled members.
• Weekly or bi-weekly meetings with members, based on acuity
• Weekly case conferences with Clinical Supervisor
• Conduct quarterly reassessments for all clients
• Complete case notes in case management program, provide quarterly metrics for external reporting, and any other reports as needed
• Initiate clinical consultations to obtain guidance for difficult members and complex cases.
• Contributes to the upkeeping of the internal Resources Directory.

CARE MANAGEMENT SERVICES INCLUDE, BUT NOT LIMITED TO :

• Serves as the primary contact to the member to coordinate access to health care, social services, and resources where the members live, seek care, or find most easily accessible.
• Conducts comprehensive risk assessments and care planning in collaboration with the members to develop a Patient-Centered Care Plan.
• Monitors implementation of Care Plans and recommend revisions or updates as necessary to accomplish the members’ goals.
• Liaises with members’ primary care provider, specialists, behavioral health providers and needed community resources for optimal execution of their Care Plan
• Educates members on self-management skills, and / or recruit support form a caregiver, to support the accomplishment of the Care Plan.
• Supports health behavior change utilizing motivational interviewing and trauma informed care practices.
• Monitors treatment adherence.
• Regularly initiates or participates in case conferences with member’s primary care provider and / or Clinical Consultant.
• Coordinates with hospital staff on discharge plan and other transitional care as feasible.
• Accompanies members to medical visits and other appointments as requested.

QUALIFICATIONS

At least 3 years of care management or care coordination experience such as LVN, Medical Assistant or Social Services,

A Bachelor’s Degree in Social Work, Psychology, Public Health, or related work / lived experience.

Experience and interest working with homeless youth and high utilizer youth

Understanding of evidence-based practices including motivational interviewing, trauma informed care and other behavior change techniques.

Good written and oral communication.

Proficient in MS Word, Excel, and online case management software

Have reliable transportation and a valid driver’s license, proof of auto insurance in effect that meets State of CA minimum coverage limits for liability insurance.

Must complete and pass a background check and work verification.

Spanish-speaking a plus.

Lived-experience a plus.

ALA offers a competitive benefits package and ALA is committed to a diverse and inclusive workplace. ALA is an equal opportunity employer and does not discriminate on the basis of race, national origin, gender, gender identity, sexual orientation, protected veteran status, disability, age, or other legally protected status.

Flexible work from home options available.