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

Application Instructions

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