Job Title: Lead Care Manager
Location: Field-based with some work from home

PopHealthCare/Emcara Health A National, Value-Based Medical Group is on the forefront of changing the healthcare landscape. Our mission is simple to lead the effort in reimagining how healthcare is delivered. Improving the lives of patients guides everything we do, and we are increasingly recognized as one of Americas leading national medical groups providing in-home and virtual care for our nations most vulnerable seniors and adults.

Our care delivery model is proven. For more than 8 years, we have been delivering the Quadruple Aim and serving those most in need. We deliver an exceptional patient experience [enterprise-wide net promoter score (NPS) of 86], while lowering total cost of care.

Our care teams understand that vulnerable populations require a new brand of care to live their healthiest life possible - home-based, advanced care meeting social needs as well as other factors that impact individuals healthcare and overall wellness.

Our core care teams are multi-disciplinary and include Lead Care Managers (LCM), Registered Nurses (RN), and Social Workers (SW).

Role Summary:

Every day, we care for patients with chronic conditions in their home. We try our best to keep them feeling well and comfortable so that they can live their lives to the fullest. But life can be tough, which makes it hard for people to stay healthy and get better when they are sick. Patients have worries such as: How will I get to the pharmacy to get my prescriptions filled? and Will I have food, transportation and enough money? As a Lead Care Manager at PopHealthCare, the goal is to build a bridge between the patients clinical and social well-being.

We believe that Lead Care Managers (LCMs) have the skills and experience to understand what our patients and caregivers are going through and help them get through difficult times. LCMs are people who come from the communities they serve. LCMs act as caring neighbors to help patients address environmental, social, and economic issues that lead to poor health. The goal is to help patients deal with the real life issues that keep them from staying healthy, help with following a medical care plan, and work on health goals by doing things like planning healthy meals or finding time to exercise. Partnering with other care team members increases the likelihood that issues from all aspects of their life impacting their health will be addressed.

Our Lead Care Managers are full-time, experienced, community health services professionals, with responsibility for conducting in-person (home, hospital, etc) and virtual visits with patients, assessing community and social support needs of patients/caregivers, and helping with patient action plans. As part of a care team, the LCM reviews a patients history and documentation before completing a visit, recommends additional interventions for the patients plan of care and/or facilitates social work and community support for an interim period based upon need. The LCM is field-based with some office duties.

Role Responsibilities:

• Engages patients and builds trusting relationships
• Screens for social and behavioral health needs
• Assists with social needs such as finding transportation, better housing or food resources, financial assistance, etc. and responds to referrals involving:

1. Unmet social needs impacting care and utilization
2. Social, family, and functional barriers to care
3. Behavioral health issues impacting care and utilization
4. Issues concerning possible need for permanent change in living arrangement to facilitate a higher level of supervision and/or care.
5. Complex family dynamic issues impacting care and utilization

• Assists patients with connecting to experts by helping to develop a personal health record, making follow-up appointments, identifying questions, and accessing needed services
• Supports Care Team Members with Technology Connections
• Provides culturally appropriate health education and support on lifestyle modifications (diet, exercise, and smoking cessation) and partners with the patients in Self-Management changes
• Participates in internal and customer-facing clinical case conferences and multidisciplinary team meetings and collaborates closely with the care team on individualized interventions to reduce patients social needs, and improve their self-management and health outcomes
• Completes follow-up and documentation tasks as required in the electronic health record
• Works with other LCMs to update and maintain a source of community organizations and programs

Qualifications

Role Qualifications:

We are searching for a special breed of health care professional who embodies the following qualities and characteristics: heart and commitment to serve vulnerable populations, passion and perseverance to achieve long-term goals (a.k.a. grit), team-based and social determinants of health orientation, and embrace change in a rapidly evolving health care delivery system. Flexible and dynamic, this self-starting individual will be a creative problem solver with a proven track record of successful implementation of innovate health care delivery solutions. They must possess excellent time management and organizational skills, with the ability to prioritize and multi-task. Additional qualifications include-

• Longtime resident of their local community with great knowledge of local community resources
• Preferred 2 years or more of experience in health or social services
• High school or GED required, associates or bachelors preferred
• Excellent oral and written communication skills & ability to carry out written and oral instructions
• Strong advocacy skills, including the ability to advocate for the patient
• Strong interpersonal and relationship building skills
• A knowledge of motivational interviewing preferred
• Ability to work independently as well as with a team with a strong desire to build collaborative relationships with all members of the field and regional teams
• Excellent time management and organizational skills are required
• Working knowledge of computers with an ability to navigate and use an electronic health record for effective and efficient documentation
• Ability to work weekends and evenings if required
• Bi-Lingual in English/Spanish preferred
• Drivers license requirements: licensed for a minimum of 3 years without restrictions; no DUI or other felony driving conviction in the past 7 years

Job Type: Full-time

Pay: $21.64 - $24.04 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Education:

• High school or equivalent (Required)

Language:

• English (Required)
• any language other than English (Preferred)

License/Certification:

• Driver's License (Required)

Shift availability:

• Day Shift (Required)

Work Location: On the road

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