Lead Care Manager JD 1
COMPREHENSIVE COMMUNITY HEALTH CENTERS, INC.
JOB DESCRIPTION
EFFECTIVE DATE:
POSITION: LEAD CARE MANAGER
REPORTS TO: BH PROGRAM MANAGER
FLSA STATUS: NON-EXEMPT
JOB SUMMARY
Oversees and implements provision of the Enhanced Care Management (ECM) services; and
identification and achievement of SMART goals and objectives with the member that meet their self-
identified strengths and health care and psychosocial needs.
ESSENTIAL DUTIES AND RESPONSIBILITIES
• Engages eligible ECM members
• Offers services where the ECM member lives, seeks care, or finds most easily accessible and
within health plan guidelines
• Connects with ECM member via phone or in-person to facilitate engagement, assessment, follow-
up, and education/training visits in order to develop care plan and address patient needs/goals.
• Works in conjunction with ECM member to identify SMART goals and objectives.
• Connects ECM member to other social services and supports he/she may need.
• Advocates on behalf of members with health care professionals.
• Uses motivational interviewing and trauma-informed care practices.
• Works with hospital staff on discharge plan.
• Accompanies ECM member to office visits, as needed and according to health plan guidelines.
• Monitors treatment adherence (including medication).
• Provides health promotion and self-management training.
• Arranges transportation.
• Responsible to convene care conference meetings.
• Coordinates with ECM resource partners to obtain data/information to ensure accurate care plan
updates.
• Utilize CCHC's EMR and other electronic tracking systems to coordinate services and input data
for reporting.
• Supervises Community Health Worker(s)
• Attends required ECM trainings.
• Facilitates internal ECM trainings/updates to CCHC clinical and administrative staff members.
• Collaborates with CCHC IT department to ensure ECM templates are appropriate and effective at
capturing needed data/information.
• Reviews existing CCHC protocols and polices to match ECM requirements.
• Develops new ECM protocols, policies, and accompanying workflows.
• Assists the ECM Director to submit required ECM reports and other internal reports.
• Other duties as assigned.
Lead Care Manager JD 2
EDUCATION, TRAINING AND EXPERIENCE
• 3-5 years of experience providing home health/case management services to low income
populations with one or more of the following: complex chronic conditions, high utilizer of
emergency room and tertiary health care services, severe mental illness, and/or homelessness.
• Bilingual in English/Spanish (oral and written), preferred.
KNOWLEDGE, SKILLS AND ABILITIES
• Ability to find solutions when barriers are identified.
• Strong documentation skills.
• Ability to multi-task and prioritize when needed.
• Ability to independently seek out resources and work collaboratively.
• Ability to read, understand and follow oral and written instructions.
• Experience and work ethics that supports working within a high functioning, team-oriented
environment.
• Demonstrates a willingness and ability to work under supervision.
• Ability to develop and maintain good working relationships with staff.
• Ability to use computer and learn new software programs.
• Excellent interpersonal skills reflecting clarity and diplomacy and the ability to communicate
accurately and effectively with all levels of staff and management.
• Demonstrates ability to work in a regulatory climate that includes oversight of state and federal
entities, payer contracts etc.
• Possesses ability to communicate effectively, both verbally and in writing.
• Possesses genuine respect for others and acceptance of their individual social and cultural traits.
• Proficient knowledge of Microsoft Outlook.
• Able to travel and attend professional meetings, conferences, trainings and clinic sites.
• Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in
multi-disciplinary teams.
• Performs other related duties as assigned.
PHYSICAL DEMANDS
Position requires prolonged sitting at a computer, some bending, lifting, stooping and stretching. Good
eye-hand coordination and manual dexterity sufficient to operate a computer keyboard, photocopy
machine, telephone, and other office equipment is also required. Employee must have normal range of
hearing and eyesight.
NOTE: The essential job functions for this position include, but may not be limited to those listed in this
job description. Employees hired for this position must be able to perform the essential functions of this
job without imposing significant risk of substantial harm to the health or safety of themselves or others.
Lead Care Manager JD 3
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