Lead Care Manager - Santa Clara, United States - Sourcewise

Description

Sourcewise mission is to provides adults and their caregivers the tools and services they need to effectively navigate their health and life options.

Through a comprehensive network of resources, Sourcewise strives to educate, prepare, support, and advocate for all adults, their families, and their caregivers within Santa Clara County.

The Care Management Department encompasses the Multipurpose Senior Services Program (MSSP), CalAim Enhanced Case Management, CalAim Community Supports and Linkages., the Enhanced Care Management Program is seeking a Lead Case Manager to provide client-centered case management and chronic condition support to frail, older adults at risk for institutionalization, eligible for long-term care, nursing facility residents who desire to return to living in the community, and adults 18+ and high utilizers of health services with the program goals of decreasing hospitalizations and preventing institutionalization.

ECM is designed to provide relatively short-term care management to address a wide variety of complex, high-acuity health care-related needs and barriers.

• Outreach and Engagement
• Comprehensive Assessment and Care Management Plan
• Enhanced Coordination of Care
• Health Promotion
• Comprehensive Transitional Care
• Member and Family Supports
• Coordination of and Referral to Community and Social Support Services

• Conduct timely assessments for incoming and existing members assigned to ensure that all necessary health and medical information is collected to develop an actionable care plan.
• Prepare and maintain comprehensive member file with all case notes, assessments and required paperwork via the reporting system.
• Prepare and articulate clear and concise case notes per member assigned to ensure that all unmet needs are identified, including the development of care planning and necessary interventions.
• Formulate measurable and achievable care plans for all members and regularly participate in case conferencing via group meetings and with Supervisor.
• Identify and establish regular connection with authorized members formal and informal support network to ensure effective care coordination.
• Interact regularly, inperson and telephonically, with the member and/or family, authorized representative, or other support person, at least monthly or more frequently, as needed.
• Initiate contact with the Primary Care Physician once a quarter to ensure coordinated service delivery and collaboration regarding the member's care plan.
• Provide active listening, problemsolving, and motivational interviewing to support health behaviors in a clientcentered manner.
• Engage in community outreach to inform potentially eligible individuals on the availability of services, programs and resources available within Sourcewise and network.
• Abide by Health Insurance Portability and Accountability Act (HIPAA) to ensure member confidentiality is upheld, including Elder Abuse Reporting, and State/Federal regulations are followed.
• Ensure accurate data entry and management of electronic client files are maintained.
• Participate in data audits and required monitoring of client files, as needed with timely response to correct outstanding errors to ensure organizational compliance.

• Bachelor's Degree in social work, psychology, counseling, gerontology, sociology or at least 2 years of experience working with highrisk adults.
• At least 2 years of experience with Case Management and Care Planning.
• Valid California Driver's License.
• Knowledge or experience in health promotion or medical social work.
• Knowledge of Care management for chronic conditions such as diabetes
• Knowledge of resources in Santa Clara County
• Knowledge of client interviewing and biopsychosocial assessment
• Knowledge of relevant laws and regulations
• Ability to relate to frail, lowincome seniors from diverse cultures and ethnicities
• Ability to establish and maintain productive and collaborative working relationships
• Effective oral and written communication skills
• Ability to maintain accurate and uptodate client records
• Effective time management skills

• Paid Time Off (vacation; sick leave; multiple holidays)
• 403(b)
• Money Purchase Pension Plan
• Medical/Dental/Vision insurance
• Shortterm & Longterm Disability insurance
• Life/AD&D insurance

• Prolonged periods sitting at a desk and working on a computer.
• Ability to legally drive and navigate within Santa Clara County for inperson encounters.
• Must be able to lift 5 to 10 pounds.

• 401(k)
• 403(b)
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick