Under general supervision from the Manager, Transition of Care, the Health Worker, Health Homes and Whole Person Care, is responsible to meet the day-to-day care coordination needs between the Alliance and contracted Community Based Care Management Entities (CB-CMEs) for the Health Home Pilot and Alameda County’s Whole Person Care Initiative. These programs target Medi-Cal members who are high risk with complex needs, providing an extra layer of services to help them achieve their health goals. The Health Worker, Health Homes and Whole Person Care, is also responsible for coordinating medical, social and or behavioral health care needs with Alliance contracted providers for members enrolled in the Pilot.
Principal responsibilities include:
· Participate actively in regular meetings of multidisciplinary Health Homes and Whole Person Care team, alongside nurse and social work staff. Work closely with other Alliance staff (medical director, analytics team, project manager) and external stakeholders on issues related to Health Homes and Whole Person Care programs.
· Establish and maintain case load of members assigned to specified Community Based Care Management Entities (CB-CMEs) and provide one to one guidance, support, education, coordination of care and other assistance to pilot members in order to support Health Homes and Whole Person Care Program goals
· Establish and maintain effective, ongoing relationships with CB-CME staff, pilot members and participating providers (including office staff)
· Provide telephonic, email, or face-to-face coordination support to pilot members to meet their treatment/care plan goals in coordination with CB-CME case management staff. This may include home visits or visits to members admitted to acute or post-acute care facilities.
· Provide support directly to CB-CME staff to help meet the treatment goals for their patients. This may include problem solving around authorizations, referrals, transfer of clinical information, transportation, interpreter services, and other issues as they come up.
· Facilitate communication and coordination among CB-CME staff, members, their caregivers and PCPs/Providers as well as other identified resources to which the patient was referred, based on each member's continued needs.
· Assist the Manager, Transitions of Care, and the Health Homes/Whole Person Care nurse and social worker in monitoring functions delegated to the CB-CMEs. This may include setting up and managing spreadsheets and entering and updating information in the electronic case management record
· Document care coordination activities, and follow up actions in a timely manner according to Alliance policies and regulatory standards in the care management systems independently and in coordination with case managers and other team members.
· Participate in case conferences and meetings with CB-CME case managers, Providers and/or Alliance in order to support effective care coordination.
· Demonstrate a comprehensive understanding of coverage and benefits in order to promote appropriate service utilization and increase participant, member, and patient knowledge and satisfaction.
· Recognize and resolve continuity of care issues or other problem areas promptly.
· Educate and answer inquiries from participants, patients, and members and/or their family members about benefits, services, eligibility and referrals with a positive and professional approach, promoting participant, patient, and member satisfaction and retention.
· Assist members in getting appointments and access to appropriate health care. Initiate follow-up to confirm and coordinate additional needs of the member to support coordination of care across care settings and needs.
· Collaborate in a positive interdisciplinary approach with other Case Managers and CM/DM staff, Medical Services, Provider Services, Member Services departments as well as community resources to ensure most appropriate level of care and optimal outcomes.
· If appropriate, work with state and federal eligibility and enrollment staff/vendors to assist in continuity in enrollment.
· Maintain security, confidentiality and integrity of electronic database
· Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
· Complete and document all telephone calls to and face-to-face meetings with members
· Explain health plan program benefits, describe the types of services the Alliance and other community partners offer and in coordination with CB-CME’s, help with risk assessments and care plan implementation.
· Accurately maintain administrative and clinical databases to ensure data integrity.
· Resolve member problem/conflicts on a one-to-one basis including reaching out to and/or meeting with other departmental staff as needed.
· Participate in community health worker trainings as determined by Manager, Transitions of Care and Medical Director. Regularly participate in Alliance meetings and meetings with community partners.
· Perform writing, administration, data entry, analysis, and report preparation.
· Communicate and coordinate with PCPs, specialists, hospitals, community agencies, transportation and other providers on behalf of participants/patients/members. Assist Health Homes/Whole Person Care nurse and social worker with administrative tasks.
· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and mouse.
· Constant use of a telephone head-set.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
· Occasional driving of automobiles.
EDUCATION OR TRAINING EQUIVALENT TO:
· Bachelor's degree or higher in health care related area of study.
· AS/AA degree or two years of college with a minimum of one year experience making healthcare related assessments and referrals, and/or experience in working with diverse clients with multiple barriers including physical and behavioral health.
· Have a cleared TB test prior to or within seven days of hire.
· Current CPR and first aid card prior to or within six months of hire is preferred
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum two year experience in the healthcare, public health, or social services sectors, preferably in a health plan setting
· Working knowledge of medical and insurance terminology, including knowledge of acute and chronic medical and behavioral health related topics.
· Minimum one year experience in working directly with clients/patients in an outpatient clinic, office, heath plan, home care or inpatient setting
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Proficiency in correct English usage, grammar, and punctuation.
· Fluency in English required.
· Fluency in Vietnamese, Cantonese, or Spanish, preferred
· Experience in managed care organization or health plan preferred
· Experience working in the safety net setting or with underserved populations preferred. If none, sensitivity to challenges of a diverse, low income community.
· Experience working with case managers (nurses and/or social workers) preferred
· Experience interacting with physicians, physician offices, hospital discharge coordinators and/or community-based programs preferred.
· Ability to multi-task and prioritize multiple projects and daily work requirements
· Working knowledge of managed care preferred.
· Working knowledge of RVS, CPT, ICD-9, ICD-10, and CPT 4 preferred.
· Communicate effectively, both verbally and in writing.
· Strong organizational skills, proactive and detail-oriented.
· Excellent active listening, interpersonal, verbal and written communication skills; ability to communicate with empathy.
· Ability to work in a team environment, as well as independently.
· Ability to act as resource.
· Familiarity with Alameda County resources a plus.