Care Manager - Home to Provider

Job Description:

Enhance seniors’ ability to manage their health and live independently by conducting care management including assessments, planning and implementing interventions, and communicating actionable client data to health provider.

• Hours:  Monday-Friday, 8am to 5pm.  Extended work hours, as needed.


• Work is primarily in the field (based out of home office), must be willing to travel in assigned area. Bi-monthly office visits to Long Beach.


• Will be expected to spend at least one day per week in medical group office, location to be determined.


• Maintain valid driver’s license, automobile insurance and reliable transportation.

Responsibilities: 

• Develops individualized care plan utilizing evidence-based guidelines and clinical knowledge for client and provider by evaluating and conducting home visits, gathering assessment information, and identifying problems, goals and interventions.


• Delivers ongoing care coordination/care management by coaching, educating, navigating and referring to appropriate care and community based resources. Assists clients and caregivers in taking an active role in chronic disease management and health prevention, by coaching, using motivational interviewing and educating about self-management tools and strategies.


• Develops cross-functional relationships with medical groups by attending appropriate meetings, working on-site, and structuring effective communication mechanisms. Coordinates with health care team to identify barriers to treatment plan by sharing home assessment information.


• Achieves best use of staff resources by supporting community health worker and dividing workload efficiently.


• Completes timely and accurate documentation in multiple computer systems to record assessment and corresponding documentation, including care plans, and progress notes.


• Exhibits strong interpersonal, critical thinking and analytical skills through positive communication with clients, caregivers, healthcare team and community agencies. Demonstrates excellent organizational, decision-making and multi-tasking skills as demonstrated by problem solving and successful outcomes. Enhances skills and knowledge by participating in team case conferences and training, per department guidelines.


• Utilizes department desktop procedures, workflows, job aids and training materials. Identifies barriers to work processes and brings to the attention of the supervisor/manager.


• Adheres to all quality, compliance and regulatory standards.


• Maintains professional and technical knowledge by attending educational workshops; reviewing and contributing to professional publications; establishing personal networks; participating in professional societies.


• Contributes to team effort by accomplishing related results as needed.