LEAD CASE MANAGER - SPANISH SPEAKER MSW

Company Description Care Partners Medicine is seeking an experienced Case Management or Social Services Professional to join our growing Care Management Team! Care Partners Medicine is a multi-faceted healthcare company who serves its patients and employees through our mission, vision, and values of providing care for those in need through Love, Compassion and Empathy.
Job Description THE PERKS.
Cultural o If you’re on our team, you’re family – and your family is family, too.
o Forward-thinking, collaborative work environment focusing on teamwork, positivity, open-mindedness and creative problem solving Transparent Executive Leadership and open-door policy o Team events, company lunches, free snacks, modern workspace Dog-friendly office – so long as Fido is trained o Generous PTO Plan and encouragement to USE IT! Financial o Competitive Base Salary based on experience ▪     Starting between $/hr 401k & Roth IRA Options Car Allowance, Cell Phone, Laptop Medical   o Multiple Health Plan Options (HMO, PPO, etc) for self and dependants o Flex-Spending Account Options o Dental, Vision and Life Insurance options Professional o You’ll work with industry experts who can mentor and support your personal and professional growth Company-paid Career development opportunities for employees who exhibit ability and desire to develop leadership skillset (YLO, Peer Development Groups, Executive Coaching) Under the direct supervision of the Enhanced Care Management (ECM) Supervisor the Lead Case Manager (LCM), will provide support to ECM-eligible patients and function as a key member of the interdisciplinary Case Management team.
The LCM will maintain his/her own caseload of ECM patients, typically between patients depending on location, acuity and other factors.
The LCM will be a hybrid-field/office position requiring him/her to meet ECM patients “where they are at,” meaning inperson in their home, or in a safe and practical location within the community.
The LCM will provide a wide range of case management services for patients within California Advancing and Innovating Medi-Cal (CalAIM) initiative.
Duties include the development of collaborative care management plans with patients, which support patient needs in the areas of physical health, mental health, substance use disorders (SUD), community-based long-term services support, oral health, palliative care, social supports, and social determinants of health.
Core ECM activities include but are not limited to, outreach, comprehensive assessment and care management, care coordination, health promotion, comprehensive transitional care, identifying patient support needs, and coordination of and referral to community and social services support.
DETAILED JOB DUTIES & RESPONSIBILITIES.
Patient outreach and engagement, including referral/record review and direct communication with patients regarding Enhanced Care Management program eligibility and services.
Support the development of a person-centered care management plan that incorporates patient's needs in the areas of physical health, mental health, SUD, community-based Long Term Services Support, oral health, palliative care, social supports, and Social Determinants of Health.
Engage and help patient participate in and manage their care and associated care plan on an ongoing basis.
Assist patients in taking an active role in managing health and social needs by coaching, using motivational interviewing, and educating about self-management tools and strategies.
Coach and support Care Management team to do the same.
Support, as part the ECM, team patient’s care coordination and organizing patient’s care activities per the care management plan.
Share and maintain information with patient's multidisciplinary team and implementing activities per the case management plan, including Community Supports through CalAIM as well as other community resources available to patients.
Communicate patients' progress by participating in interdisciplinary meetings and evaluations; disseminating results and obstacles to therapeutic team and patient family.
Support patient engagement in treatment including coordination or medication review and/or reconciliation, scheduling appointments with PCP and/or Specialists, appointment reminders, coordinating transportation, identify and address other barriers to patient’s engagement in treatment Ensure regular contact with the patient and their family member(s), guardian, caregiver, and/or authorized support person(s) as part of care coordination Support patient in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic condition Effectively manage crisis by using Motivational Interviewing and De-escalation skills, both in support of the patient and other team members Support patients with linkage to transitional care resources for patients during discharge from hospital or institutional setting including (where appropriate) developing a transition care plan, and coordination of care to provide adherence support and referrals to appropriate resources and community supports, as needed.
Assist patient in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), CalFresh, cash aid, and obtaining required documentation to apply (ID, birth certificate, immigration status, financial records, marriage/divorce records, proof of medical conditions, etc.
Facilitates referrals to Community Health Services when appropriate.
Offer exceptional care coordination skills that include warm hand-offs and closed-loop referrals Maintains current patient records by reviewing case notes; logging events and progress effectively and efficiently in the electronic health record (EHR).
Monitors patient’s treatment compliance and referral outcomes.
Assists as part of the ECM team with the coordination to lower level of care.
Prepares patients' successful graduation from program by reviewing and amplifying graduation and treatment plans; coordinates treatment plan requirements and referrals to community resources; orients and trains family members; providing resources and notifying other providers on the health team when care management plan goals are met.
Performs other duties as assigned.
Qualifications MINIMUM QUALIFICATIONS.
A bachelor's degree (social work, psychology or related field preferred) and 1-2 years’ experience providing case management, social services or health care coordination OR High School Diploma and 4+ years of Case Management or Social Services experience) Experience with Community Outreach and Field-based resource linkage, preferred Strong knowledge of local Healthcare, Community and Social Service resources required.
Strong computer skills, including able to easily navigate around health care systems Bilingual in Spanish preferred Must have valid CA driver’s license  Ability to move between sites and perform duties in the field in a variety of settings Knowledge of or reasonable ability to learn use of Electronic Health Record PHYSICAL DEMANDS.
Standing, walking, sitting, typing, reaching, bending, moving and/or lifting up to 25 pounds.
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