JOB ID: 1413
The Health Homes Program (HHP) services eligible Medi-Cal beneficiaries with complex medical needs and chronic conditions who may benefit from enhanced care management and coordination. The HHP coordinates the full range of physical health, behavioral health, and community-based services and supports needed by eligible beneficiaries.
The Health Home Care Manager guides clients with chronic illness(es) through the health care system by assisting with access challenges, developing relationships with service providers, and tracking interventions and outcomes. The Health Home Care Manager (HHCM) acts as the team leader providing direct services to clients, including the completion of needs assessments, development of patient-focused care plans, periodic reassessments, and comprehensive service coordination. The HHCM also functions as an advocate for clients, both within BH and with external service providers, and as a primary conduit of information between and among the client and providers. As a team leader the HHCM is responsible for the overall provision and coordination of services for the entire assigned caseload.
Duties and Responsibilities Include:
- Provide all necessary and indicated direct and referral services (including crisis intervention and health education) to a caseload of approximately 50-80 clients and any collateral person, including their children.
- Conduct initial assessments and periodic reassessments of clients’ needs, including medical, mental health, substance use, financial, housing, and support needs.
- Develop patient-focused care plans with documented input and approval from other providers and the client in compliance with Health Home standards.
- Work with the medical staff to develop, implement, and coordinate the care plan for clients with chronic illnesses, such as diabetes, asthma, congestive heart failure, hypertension, behavioral health conditions, and HIV, among other illnesses, based on the Health Home chronic disease care coordination model standards.
- Conduct home/field visits and maintain client engagement in accordance with program standards.
- Coordinate client services with internal and external service providers through regular case conferencing.
- Document client outcomes from the care plan in the case record and ensure appropriate record documentation for entire caseload.
- Assist in coordinating care with pharmacies, insurance companies, hospital discharge planning, and other providers in the network.
- Ensure that information-sharing is timely, and that it goes when and where it is needed.
- Handle appointments and non-appointment related calls from patients, as well as providers, and keep patients informed regarding scheduled appointments and ensure adherence to their medical appointments.
- Support clients and providers in the medication refill process.
- Schedule and document care conferences with client’s care team to ensure that the care team members are well-informed of the required care plan implementation for each patient and to obtain necessary updates and paperwork.
- Provide patient with general information on healthy lifestyle, prevention and primary care for their chronic condition(s).
- Monitor patient satisfaction surveys/complaints and appropriately follow-up and respond to the same, as necessary.
- Use and update the directory of resources in the service area to meet basic health and human needs.
- Serve as a back-up to other Health Homes Care Managers or to other care team members, as needed.
- Participate in QA/QI activities and designated/required program and staff meetings, including internal and external trainings.
- Perform other duties as may be assigned.
Minimum Requirements for Employment:
- Bachelor’s degree in social work, psychology or a related health/human services field. Masters degree is preferred.
- Good oral and written communication skills, as well as good interpersonal and customer service skills and the ability to effectively work as part of a team.
- Demonstrated computer proficiency, particularly with Microsoft Office (Word, Excel) and electronic health record systems.
- Knowledge of chronic medical conditions, mental illness, substance use, and homelessness, as well as a basic understanding of public benefits and entitlements.
- Good organizational and time management skills and demonstrated ability to problem- solve using good judgment in a complex social and health services environment.
- Good working knowledge of local social and health services resources and the necessary skill to promptly acquire and effectively use such knowledge and information.
- The ability to work effectively with people from diverse cultures and socioeconomic backgrounds.
- Demonstrated Spanish language (oral and written) proficiency preferred.
- Driving is an essential function of this position
- Must have Valid CA Driver's License
- Must provide proof of insurance coverage
- Must be able to qualify for PATH insurance coverage
The employee may be in contact with individuals and families in crisis who may be ill, using alcohol and drugs, and who may not be attentive to basic personal hygiene, health and safety practices. The employee may experience a number of unpleasant sensory demands associated with the client’s use of alcohol and drugs, and lack of personal hygiene. The employee must be ready to respond quickly and effectively to many types of situations, including crisis situations and potentially hostile situations. The noise level in the work environment is usually moderate in an office setting. Sometimes work may become stressful when working under pressure.
The physical demands 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 individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to stand, sit, walk, stoop, talk, hear, reach above and below shoulders; use hand and finger dexterity, keyboarding and making and receiving telephone calls. The employee may be required on occasion to lift and or carry up to 20 lbs.
PATH (People Assisting The Homeless) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, PATH complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
How to apply:
Please visit the Path Career Site
to apply online. Search for Job #1413
to submit your application. A resume is required.