DSNP CICM Care Manager I

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work - Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP's focuses on 5 Core Values in the workplace:

* Integrity

* Accountability

* Collaboration

* Trust

* Respect

Disclaimers:

* Flexible work schedule is based on job duties, department, organization, or business need.

* Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The D-SNP CICM Care Manager I supports members with complex medical, social and/or behavioral health needs. Performs assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's medical and psychosocial needs. Ensures the appropriateness of the individualized care plan from member with complex health, social or behavioral health needs. Works with members and providers to support achievement of goals of care. Provides disease self-management education, health coaching, coaching on social skills and provides needed clinical support and oversight to care navigators. Monitors health outcomes, goal attainment. Performs comprehensive assessment and care planning associated with CICM for members in populations of focus. The D-SNP CICM Care Manager I is the member's primary point of contact and Lead Care Manager for the most vulnerable GCHP D-SNP members. The CICM Care Manager provides efficient and effective Care Management to qualified members using clinical judgement and critical thinking skills, ensures all tasks are timely and in compliance with requirements per GCHP's DSNP Model of Care approved by CMS and DHCS. Through in-home face-to-face visits and telephonic engagement, the D-SNP CICM Care Manager I provides education and coaching including on chronic conditions, connects members to resources, and advocates for the individual.

Amount of Travel Required: 30 - 50%

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

* Completes telephonic calls and in-person field visits to conduct the HRA with DSNP members. Works with the member to develop an individualized care plan (ICP) and with interdisciplinary care team (ICT) to develop and assess health interventions on-going.

* Develop individualized care plan (ICP) with the input of the member, PCP and other providers as needed to address identified member problems using evidence-based goals and interventions.

* Participate in interdisciplinary care team (ICT) meetings and be able to present complex medical cases before the team.

* Work collaboratively with health plan's providers, particularly member's primary care providers and specialist, in order to provide highly coordinated and often specialized care including but not limited to palliative care, county behavioral health, CBAS, and LTSS providers.

* Responsible for the time sensitive processes for initiating cases, managing referrals to the department, appropriate documentation, routing of information, performing computer data input, faxing, emailing, filing of confidential member information, and maintaining logs of activity, etc.

* Conducts telephonic outreach calls to members/caregivers regularly and evaluates and documents their progress towards their healthcare goals. Sets up provider/specialist appointments and follow up on treatment plans. Assess changes in member status that warrant additional HRA or ICP review and updates.

* Transitional Care Services: Provides member and caregiver support, coordination, education and advocacy during all in-patient care stays and transitions between care settings ultimately to home through the entire episode of care.

* Engages members as appropriate to participate in the CM/Disease Management and other specialized care programs by reaching out and promoting the programs to address member's unmet needs.

* Review medical records and community assessments for member history and care planning.

* Coordinate care to ensure a seamless experience for the member with non-duplication of services.

* Perform medication reconciliations per initial assessments and transitions of care.

* Provide health promotion and self- management training.

* Evaluate assessment findings against evidenced-based guidelines to develop a plan of care based on member needs and findings with collaboration from interdisciplinary team.

* Identify potential barriers to adherence to treatment plan and modify plan by mutual agreement with the member.

* Educate member/caregiver on specific disease using approved evidence-based guidelines and modify plan of care/goals based on member's readiness to change.

* Handles the incoming and outgoing calls to members/caregivers and providers to coordinate care as identified in the care plan.

* Initiates follow up calls to members to administer screenings or confirm linkage to appropriate resources. Creates referrals and performs follow-up with service providers and community partners.

* Care Coordination, Case Management, and System Navigation for Medicare and MediCal services: Participating in care coordination and case management. Making referrals and providing follow-up. Coordinating transportation to services and helping address barriers to services. Documenting and tracking individual and population level data. Informing people and systems about community assets and challenges. Linking member to community resources to address the Social Determinants of Health (SDoH) of the member.

* Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems: Educating individuals and communities about how to use health and social service systems (including understanding how systems operate). Educating systems about community perspectives and cultural norms. Building health literacy and cross-cultural communication.

* Providing Culturally Appropriate Health Education and Information: Conducting health promotion and disease prevention education in a manner that matches linguistic and cultural needs of members. Providing necessary information to understand and prevent diseases and to help members manage health conditions (including chronic disease).

* Providing Coaching and Social Support: Providing individual support and coaching. Motivating and encouraging people to obtain care and other services. Supporting self-management of disease prevention and management of health conditions (including chronic disease). Planning and/or leading support and health education groups.

* Advocating for Individuals and Communities: Advocating for the needs and perspectives of communities. Connecting to resources and advocating for basic needs (e.g. food and housing). Conducting policy advocacy for their communities.

* Conducting Outreach: Case-finding/recruitment of individuals, families, and community groups to services and systems. Follow up on health and social service encounters with individuals, families, and community groups. Home visiting to provide education, assessment, and social support. Presenting at local agencies and community events.

* Attending regular staff meetings, on-site monthly trainings and other meetings as requested. Managing assigned caseload.

* The position is responsible to ensure the plan meets the contractual and regulatory requirements and timelines by maintaining accurate documentation and following up with the member and provider as needed.

* Perform other duties as assigned.

MINIMUM QUALIFICATIONS

Required Education and Experience:

* Bachelors or Masters degree in Social Work,

* Minimum of three (3) years of social work in a healthcare or public health setting preferred or

equivalent work experience considered or

* BSN or MSN required with Registered Nurse license, active and unrestricted licensed in the State of California before start of work.

* Minimum of three (3) years of nursing/care management in a healthcare or public health setting preferred or equivalent work experience considered.

Preferred Education and Experience:

* Training in health education for chronic diseases, motivational interviewing is preferred.

Equivalent In lieu of degree:

* Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position for the BA/BS or MA/MS degree. Two years of experience must be added in lieu of a degree.

* BSN or MSN may not be substituted w/ experience.

KNOWLEDGE, SKILLS & ABILITIES

* Ability to always maintain a calm demeanor, including during highly charged situations.

* Ability to establish, nurture and maintain strong and effective working relationships with GCHP staff, governmental and regulatory staff, legal counsel, and others.

* Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.

* Ability to assume responsibility and exercise good judgment with making decisions within the scope of the position.

* Knowledge of community resources in area of residence.

* Comfortable working with diverse populations.

* Exceptional ability to connect and engage with people.

* Ability to work in various environments including 1:1 in member's homes, clinical settings, and/ or shelters.

* Excellent verbal and written communication skills.

* Detail oriented, organized and possess time management skills

Preferred Qualifications:

* Bilingual in English and Spanish

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s) (Current Licensed Registered Nurse, Clinical Social Worker or other Licensed Behavioral Health Professional in the state of California)

Competency Statements

* Management Skills - Ability to organize and direct oneself and effectively supervise others.

* Business Acumen - Ability to grasp and understand business concepts and issues.

* Decision Making - Ability to make critical decisions while following company procedures.

* Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

* Interpersonal - Ability to get along well with a variety of personalities and individuals.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

* Consensus Building - Ability to bring about group solidarity to achieve a goal.

* Relationship Building - Ability to effectively build relationships with customers and co-workers.

* Presentation Skills - Ability to effectively present information publicly.

* Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.

* Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.

* Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.

* Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

* Judgment - The ability to formulate a sound decision using the available information.

* Communication, Oral - Ability to communicate effectively with others using the spoken word.

* Communication, Written - Ability to communicate in writing clearly and concisely.

* Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.