Job Description

Job Description:
Under the direction & supervision of the CWO RN, the Lead Care Manager is responsible for conducting patient orientation for individual patients, families and groups, assisting patients to complete health risk assessments entering results into the electronic health record (EHR), representing client  at health fairs & community events, assisting with clinic & community based health education & health screening, promoting & encouraging positive health behaviors, and assisting patients at IHC to access health and social services. He/she will participate in organizational improvement activities as needed.  This position includes working & collaborating with community based organizations and performing other activities as requested.  The IHC is a Patient Centered Health Home and all employees are an integral part of this model of care delivery.

Enhanced Care Management (ECM)
Provides clinically necessary services to adults and their families, including evaluation, assessment, crisis intervention, resource and plan development, case management, after- care planning and outreach services.
Coordinate client treatment plans with other IHC Departments and public and private agencies, and assist the Department in establishing and maintaining a network of supportive resources through outreach and referral
Ability to chart and write clear comprehensive notes
Participate in networking with partnering agencies, including Santa Clara County and ECM Workgroups 
Conduct patient enrollments/ risk assessment data and enter data into EHR
Provide information and referrals regarding outside health and social services support
Liaise with health care providers, social service providers, and peers to connect patients with services, establish new services and programs, and arrange for community presentations and events
Promote and encourage positive health behaviors and lifestyles by utilizing behavior change strategies in group and individual settings
Serve as a role model and mentor for patients and peers, perform community and clinic based health intervention, and advocate for health and social service needs
Translate & Interpret, use the knowledge of language, cultural practices & beliefs to support patients in a manner that is culturally & linguistically appropriate & assist other health professionals to provide culturally sensitive care
Communicate effectively with staff, the community, and general public in a manner that promotes trust and cooperation 
Document and maintain a complete record of work performed, statistics, assessments, and correspondence with patients, community organizations, and professionals
Schedule weekly meetings with ECM Managers and other staff to report and review program progress
Document and maintain a complete record of work performed, statistics, assessments, and correspondence with patients, community organizations, and professional
Outreach and enroll patients into the ECM Program
Interact with patients as frequently as determined by their care coordination bundle.
Provide health education
Meet enrollment and productivity targets set by ECM Manager
Health Education
In addition to providing health education to ECM patients, ECM Health Educators will be able to provide health education to all IHC patients
Conduct health education activities for chronically ill patients:
Conduct one-on-one and group health education sessions at IHC sites
As part of the IHC Care Team, work closely with IHC staff such as medical providers, medical assistants, and RN to meet the needs of our patients
Collaborate with other IHC departments in different outreach activities: health fairs, community events, and community presentations when requested
Develop and present health education and promotion programs at training workshops, conferences, and school or community events when required
Prepare and distribute health education materials including reports, bulletins, and visual aids such as films, videotapes, photographs, and posters
Develop and maintain cooperative working relationships with agencies and organizations interested in public health care
Ability to sit, stand and walk for extensive periods of time
Manual and finger dexterity and eye-hand coordination for nursing care
Ability to lift up to 35 pounds
Ability to stoop, squat, or bend frequently
corrected vision and hearing within normal range to observe and communicate with patients and professional staff

Exposure to all patient elements, including communicable disease and blood borne pathogens.  Will be working in a fast paced medical environment which can be stressful and constantly changing conditions. Normal working hours are from 8:00 am until 5:00 pm with one hour for lunch.  However, working hours may vary depending upon need.  Will need to be flexible in performing tasks with limited discretion in making judgment decisions.

Two-years of equivalent work or life experience with low income population with multiple needs, chronic diseases, or other health conditions
Bi-lingual in English and Spanish preferred
Knowledge of theory and treatment practices of interpersonal and social problems; community mental health; alcohol and other drug abuse interventions; suicide prevention; and community agencies and resources that assist with emotional wellness
Understanding of California mandated reporting laws
Excellent interpersonal, verbal and written skills
Ability to maintain good working relationships with staff
Ability to provide public presentations to others in the field
Experience working with patients afflicted with chronic diseases such as diabetes, hypertension and dyslipidemia a plus
Knowledge of and ability to work with the American Indian community and other minority populations preferable
Flexibility, initiative, reliability, and creativity
Ability to function independently and as a team member within diverse environments as well as with a diverse staff composition
Demonstrated ability to perform multiple administrative functions simultaneously in an accurate, organized, & efficient manner.
Ability to multitask & thrive in a fast-paced, constantly changing environment
Ability to carry out all responsibilities in an honest, ethical & professional manner and demonstrate good judgment
Possession of a valid California Driver License, automobile insurance, and a clean driving record
Ability to work evenings and weekends as needed


Application Instructions

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