Care Manager - Home to Provider

Qualifications

• 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 to achieve HCS and the Medical Group outcomes.


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

Requirements

• Bilingual Spanish/English.


• 8+ years in medical managed care field with a Bachelor’s Degree, or 3+ years in medical managed care field with a Master’s Degree in Social Work.


• Gerontology Demonstrated knowledge of assessment, health and functional problems of older adults.


• Knowledge of community resources for seniors.


• Basic knowledge of related, CMS and DHCS regulations.


• Proficient in MS Office.


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