Care Manager - CCM Job at Vista Community Clinic
Overview:
Qualifications:
Vista Community Clinic is a private, non-profit, multi-specialty outpatient clinic providing care in a comprehensive, high quality setting. Located in San Diego, Orange and Riverside counties, we work to advance community health and hope by providing access to premier health services. We are looking for dedicated, motivated, enthusiastic team players who want to make a difference in the community. Our competitive compensation and benefits program includes health, dental, vision, company-paid life, flexible spending accounts and a 403(B) plan, for eligible employees. VCC is an equal opportunity employer.
Responsibilities:
Operating as part of the patients’ multi-disciplinary care team, is responsible for interacting directly with the assigned Chronic Care Management (CCM) members and/or family, authorized representative(s), caretaker(s) and/or other authorized support person(s) as appropriate to coordinate all aspects of CCM. Work with the Clinical Nurse Specialist and other program staff to care coordinate assigned CCM patient panel to ensure appropriate input is obtained to effectively coordinate all primary, behavioral, specialty, and other services that address social determinants of health (SDOH) and chronic care management.
Conduct outreach, enrollment and care management to selected Medicare patients- Develop a person-centered, electronic care plan based on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment
- Coach patients and caregivers using evidence-based motivational interviewing techniques and trauma-informed care language to address critical issues to help patients develop
achievable self-management care plan goals, presenting new skills using a step-by-step process
- Act as point of contact for patients and families involved in patients’ care team through any form of agreed-upon communication
- Support patients in the development of health care goals by conducting appropriate assessments that uncover comprehensive physical, mental, and social needs
- Identify and initiate referrals for social service programs, such as financial, community and state supportive services alleviating housing instability and other social determinants of
health
Qualifications:
Minimum
- Bachelor's degree in social work, psychology, counseling, behavioral science
- Two years’ experience in a healthcare setting, preferably providing direct patient care, or with duties involving patient education and advocacy.
- Resourceful community liaison experience navigating through complex health systems and community services
- Bilingual English/Spanish
- Valid CA driver’s license and vehicle insurance, reliable transportation
Preferred Qualifications
- Master's degree in Social Work (MSW) or other related field
- Phlebotomy certification
Required Skills/Knowledge/Abilities
- Ability to communicate effectively, verbally and in writing, to individuals and groups from varying cultural, ethnic, social and educational backgrounds and within the constraints of government funded programs.
- Proficient in MS Office and Outlook
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