Master of Social Work (ECM) 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:

The Enhanced Care Management program provides a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need members enrolled in MediCal managed care health plans. The MSW Lead Care Manager will work with leadership, providers and managed care plans to determine the needs of high-acuity, vulnerable patients. This will include providing basic housing assistance, patient tailored intensive case-management, and developing a care/service plan. Provide linkages to medical, psychiatric, social, educational and other supportive services as needed. The MSW Lead Care Manager will also work with the Community Supports Program staff to provide team-based, patient-centered care management for homeless and at-risk of homelessness patients. The goal of the ECM program is to effectively manage high utilizers and homeless patients during their continued care to ensure that their medical and psychosocial needs are met and to minimize the likelihood of preventable hospital admissions and emergency department utilization.

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

• Conducts initial screening, assessments, and reassessments to determine the continued needs of the client.

• Conducts outreach, enrollment, monthly reporting, and accurate completion of comprehensive risk assessments and care plans.

• Conducts proper intake steps such as patient data collection, eligibility, program enrollment, care plan development, and assessment of needs.

• Documents in EMR and external health plan portals.

• Works with leadership, providers, and managed care plans to develop and implement patient-focused care plans for clients with chronic conditions.

• Provides direct care management services to ECM participants in their assigned case load in line with ECM guidelines and recommended services.

• Conducts regular reviews of patients’ charts to ensure quality services are provided and documented by Lead Care Managers consistently and accurately.

• Responds to patient inquiries and refers members to other departments, social services, or support services as needed.

• Works with the Housing Navigation team to ensure enrolled patients, who are experiencing homelessness or are at risk of homelessness, receive proper services.

• Performs other related 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:

• ACSW preferred, not required.

• Master’s degree required.

• Three years of experience in health care, case management, or a related field.

• Knowledge and experience with Electronic Medical Records.

NECESSARY SKILLS:

• Ability to communicate effectively in both written and verbal form to patients, public, medical staff, and physicians.

• Excellent counseling skills and ability to relate to multi-ethnic communities and varied income levels.

• Strong interpersonal skills to establish productive working relationships with a multidisciplinary team and support services.

• Ability to work independently, collaboratively, and possess strong time management skills.

• Knowledge of the Care Process and ability to apply all steps.

• Knowledge of insurance coverage and the insurance eligibility process.

• Knowledge of the functions and services of local community health agencies and community organizations.

• Excellent organizational skills and attention to detail.

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.