Enhanced Care Management; ECM Lead Case Manager

Overview

Our mission at Good Seed CDC is dedicated to improving the health status of our members through an integrated managed health care delivery system.

• Engages patients and offers and/or facilitates care management services where the patient lives, seeks care, or finds most easily accessible.
• Conducts comprehensive risk assessments and develops patient-centered Care Plans that include goals based on the patients’ physical and psychosocial health needs and personal preferences.
• Oversees effective implementation of Care Plans, ensuring the initial plan is drafted within 30 days from the patient’s enrollment and updated as necessary, but no less than once per quarter thereafter.
• Educates patients on self-management skills and/or recruits support from a caregiver/family member to support the accomplishment of the Care Plan.
• Supports health behavior change utilizing motivational interviewing and trauma-informed care practices.
• Monitors treatment adherence.
• Regularly initiates or participates in case conferences with clinical providers.
• Connects patients to social services, including housing, transportation, etc., as needed to achieve the patient’s goals and well-managed care.
• Coordinates with hospital staff on discharge plans and with other transitional care as feasible.
• Accompanies patients to office visits, as needed and according to health plan guidelines.
• Maintains a regular contact schedule with enrolled patients that includes at least one in-person encounter per month.
• Documents care management encounters in the Electronic Health Record (EHR) with the appropriate billing codes and internal tracking logs.
• Performs other duties as assigned.
• Open to seeing patients in person or at their location of preference.

• High School Diploma, Bachelor’s in Social Services preferred.
• 2 – 3 years of experience in community health or a social service setting required.
• 2 – 3 years of case management / care coordination experience preferred.
• Bilingual required:
  English and Spanish or Armenian fluency required.
• Proficiency in Microsoft Office Suite products.
• Valid driver’s license and willingness to drive to communities where ECM members live.
• Must be able to work in an interdisciplinary team setting.
• Effective communication and interpersonal skills.
• Experience with Electronic Health Records preferred.
• Ability to independently seek out resources and work collaboratively.

• Job Type: Full-time
• Expected hours: 40 per week
• Benefits: Paid Holidays/PTO Schedule; 8-hour shifts;
  Monday to Friday
• Work setting: Office;
  Telehealth
• Ability to commute/relocate: SPA 6 and 8 - Reliably commute or planning to relocate before starting work (Required)
• Experience: Healthcare: 1 year (Preferred);
  Case management: 1 year (Preferred)
• Language: Spanish (Required)
• License/Certification: Driver’s License (Required)
• Willingness to travel: 75% (Preferred)

Work Location:

In person and Remote (Client schedule appointments and meetings)