Lead Care Manager (LCM)
hace 16 días
Riverside
The Bilingual Lead Care Manager partners with Care Team Operations, Clinical Operations, Compliance, Community Health Workers, Behavioral Health staff, and external providers (medical, housing, and social services) to ensure seamless, culturally responsive, member-centered care coordination. The bilingual LCM additionally supports members with limited English proficiency by facilitating communication, translation, and cultural interpretation as needed. Responsibilities • Serve as the primary point of contact for assigned members, building trust and maintaining active engagement through consistent outreach, relationship-based strategies, and a trauma-informed approach. Provide all communication in the member’s preferred language., • Conduct comprehensive assessments (physical, behavioral, functional, social) and develop person-centered care plans that reflect the member’s goals, risks, preferences, cultural needs, and social determinants of health., • Implement, monitor, and update care plans following transitions of care, significant changes in condition, or required reassessments; ensure timely and compliant submission of all care plans., • Coordinate services across the continuum—including medical, behavioral health, housing, transportation, social services, and community programs—to reduce fragmentation and remove barriers to care., • Conduct required in-person home or community visits based on member need and risk stratification and maintain a compliant monthly visit structure., • Utilize motivational interviewing, coaching, and health education to promote behavioral change, self-management, and long-term member stability., • Identify gaps in care, service delays, lapses in benefits, unmet needs, and environmental risks; collaborate with internal and external partners to resolve issues quickly and effectively., • Maintain accurate, timely, audit-ready documentation of all interactions, assessments, and interventions using required HHN platforms, including eClinicalWorks (ECW), Google Suite, RingCentral, PowerBI dashboards, and payer portals., • Meet or exceed HHN and payer productivity standards, including encounter metrics, outreach requirements, documentation timelines, and quality measures., • Actively participate in multidisciplinary case reviews, team huddles, care conferences, and escalations with nurses, behavioral health staff, CHWs, care operations, and compliance., • Coordinate and schedule appointments with primary care, specialists, behavioral health providers, and community partners; manage referrals, transportation, and follow-ups to ensure continuity of care., • Support hospital discharge (TOC) planning through follow-up scheduling, care transitions, medication reconciliation support, and education on discharge instructions., • Assist members in navigating plan eligibility, redeterminations, documentation, social service applications, housing resources, and crisis interventions., • Maintain active and professional communication with members and care partners through HHN-approved channels, including RingCentral, secure messaging, SMS workflows, and phone., • Participate in HHN’s continuous quality improvement efforts, identifying workflow gaps, documenting barriers, sharing insights, and contributing to best-practice development., • Uphold confidentiality and adhere to all HIPAA and payer regulatory requirements across all areas of care delivery., • Open to seeing patients in their home or their location of preference., • Provide real-time interpretation and translation support (verbal and written) for members and families with limited English proficiency., • Help bridge cultural gaps that may impact communication, trust, adherence, or engagement. Skills Required • Fluency in English and another language (Spanish preferred); ability to read, write, and speak at a professional level., • Strong ability to build rapport and trust with diverse, high-need member populations., • Proficiency in using eClinicalWorks (ECW), Google Suite (Docs, Sheets, Drive), RingCentral, and virtual communication tools., • Ability to interpret and use PowerBI dashboards, reporting tools, and payer portals., • Demonstrated skill in conducting holistic assessments and developing person-centered care plans., • Experience with motivational interviewing, trauma-informed care, or health coaching., • Strong organizational and time-management skills, with the ability to manage a complex caseload., • Excellent written and verbal communication skills across in-person, telephonic, and digital channels., • Ability to work independently, make sound decisions, and escalate appropriately., • Knowledge of Medi-Cal, SDOH, community resources, and social service navigation., • High attention to detail and commitment to accurate, audit-ready documentation., • Ability to remain calm, patient, and professional while supporting members facing instability or crisis., • Comfortable with field-based work, home visits, and interacting in diverse community environments., • Cultural humility and demonstrated ability to work effectively across populations with varied lived experiences. Competencies • Member Advocacy: Champions member needs with urgency and integrity., • Operational Effectiveness: Executes workflows consistently and flags process gaps., • Interpersonal Effectiveness: Builds rapport with diverse populations., • Collaboration: Works effectively within an interdisciplinary care model., • Decision Making: Uses judgment to escalate or intervene appropriately., • Problem Solving: Identifies issues and creates practical, timely solutions., • Adaptability: Thrives in a fast-growing, startup-style environment with evolving processes., • Cultural Competence: Engages members with respect for their lived experiences., • Documentation Excellence: Produces accurate, timely, audit-ready notes every time., • Strong empathy, cultural competence, and commitment to providing individualized care., • Ability to work effectively within a multidisciplinary team environment., • Exceptional interpersonal and communication skills, with a focus on building trust and rapport with diverse populations. Bilingual Communication (interpretation + translation) Job Requirements • Education:, • Bachelor’s degree in Social Work, Psychology, Public Health, Human Services, or related field preferred; equivalent experience considered., • Licensure:, • Not required; certification in care coordination or CHW training is a plus., • Experience:, • 1–3 years of care management or case management experience, preferably with high-need Medi-Cal populations., • Experience in community-based work, homelessness services, behavioral health, or SUD settings strongly preferred., • Familiarity with Medi-Cal, ECM, and community resource navigation., • Travel Requirements:, • Regular travel for in-person home or community visits (up to 45%)., • Physical Requirements:, • Ability to perform home visits, climb stairs, sit/stand for prolonged periods, and lift up to 20 lbs if needed.
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