ECM Clinical Consultant at Central Neighborhood Hlth Fdn – San Bernardino, California

INTRODUCTION:

Central Neighborhood Health Foundation is a Federally Qualified Healthcare Center (FQHC) committed to the Triple Aim as described by the Institute for Healthcare Improvement. Improving the US health care system requires simultaneous pursuit of three aims: 1) improving the experience of care, 2) improving the health of populations, and 3) reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an "integrator") that accepts responsibility for all three aims for that population.

SUMMARY:

Enhanced Care Management (ECM) benefit is a new, statewide benefit established by the Department of Health Care Services (DHCS) to provide a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need Medi-Cal beneficiaries enrolled in Medi-Cal managed care. Enhanced care management is a collaborative and interdisciplinary approach to providing intensive and comprehensive care management services to populations of focus.

The following seven core services will be provided at the point of care: Outreach and engagement; Comprehensive assessment and care management plan; Enhanced care coordination; Health promotion; Comprehensive transitional care; Member and family supports; Coordination of and referral to community and social support services.

ECM population of focus will be: Individuals and families experiencing homelessness; High utilizer adults; Adults with serious mental illness (SMI) or substance use disorder (SUD); Adults and children/youth transitioning from incarceration.

ESSENTIAL DUTIES AND RESPONSIBILITIES include but are not limited to the following functions:

• Responsible for ensuring clinical assessment elements leading to the creation of the plan of care are under the direction of an independently licensed clinician.

• Review and inform the care team.

• Act as clinical resource for care team, as needed.

• Facilitate access to primary care and behavioral health providers, as needed to assist care coordinator and team

• Other duties as assigned.

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE:

• Graduate from an approved nursing program.

• California license as a Registered Nurse or LCSW

• Must be sensitive to the needs of the patients in a community health care setting in the areas of health and social services as one component.

• Bilingual in English/Spanish is desirable but not necessary.

NECESSARY SKILLS:

• Demonstrates effective verbal and written communication that is clear, well organized and demonstrates an understanding of audience needs.

• Through genuine and positive communication makes each patient feel informed, understood and special.

• Must have a high level of accuracy, time management skills, and possess strong organizational skills.

• An effective team player who contributes valuable ideas and feedback can be counted on to meet commitments.

• Pursues activities with focus and drive, defines work in terms of success and can be counted on the complete goals.

Policy

Punctual and regular attendance is an essential responsibility of each employee at CNHF. Employees are expected to report to work as scheduled, on time and prepared to start working. Employees also are expected to remain at work for their entire work schedule. Late arrival, early departure or other absences from scheduled hours are disruptive and must be avoided.

This policy does not apply to absences covered by the Family and Medical Leave Act (FMLA) or leave provided as a reasonable accommodation under the Americans with Disabilities Act (ADA). These exceptions are described in separate policies.

WORK ENVIRONMENT

Described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. Variations in conditions may occur under certain circumstances.

CONFIDENTIALITY

Maintains patient, employee, and Foundation confidentiality at all times, discussing patient or employee business only with appropriate parties who have a bona fide need to know; and communicating only the minimum amount of information necessary with respect to protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

1. AGREEMENT AND ACCEPTANCE

2. I HAVE READ THE ABOVE JOB DESCRIPTION AND FULLY UNDERSTAND THE REQUIREMENTS SET FORTH AND WILL PERFORM ALL DUTIES AND RESPONSIBILITIES TO THE BEST OF MY ABILITY.