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.

Provide direct oversight to the Enhanced Care Management program for select managed care plans and care managers including program development, implementation, supervision and training. Operate as part of the patients’ multi-disciplinary care team and responsible for interacting directly with the assigned health plan’s ECM Members and/or family, Authorized Representatives (ARs), caretakers and/or other authorized support person(s) as appropriate to coordinate all aspects of ECM and any Community Supports. Work with the ECM Clinical Nursing Specialist and other program staff to care coordinate designated populations of focus panel to ensure appropriate input is obtained to effectively coordinate all primary, behavioral, developmental, oral health, upports (LTSS), Community Supports and other services that address social determinants of health (SDOH).

Essential Job Functions - Supervisor Responsibilities

• Provide supervision to assigned program staff and complete associated paperwork as required, including evaluations.
• Responsible for tracking and reviewing daily billing and coding reports to ensure monthly service expectations are met.
• Provide coaching to address performance improvement for direct reports.
• Monitor, assign, and track internal and external program referrals.
• Responsible for oversight of internal program reporting and identifying/addressing deficiencies in performance and quality of care.
• Participate in the development of workflows and assist the grant writing team, as needed
• Attend and facilitate internal staff and department meetings and external partner and/or collaboration meetings as required
• Identify and foster partnerships with community based organizations for program referrals
• Assist Program Manager in identifying outreach and enrollment strategies
• Maintain knowledge of Health Plans platforms and documentation
• Participate in Health Plans Audits and support development and implementation of corrective action plans
• Assist in training of Care Manager’s workflows and templates
• Perform other duties as assigned

Care Manager Responsibilities

• Maintain a partial caseload of enrolled patients across all San Diego Health Plans, based on program need.
• Conduct outreach, enrollment and care management to selected population of focus determined by assigned health plan(s)
• Develop an individualized comprehensive management care plan integrating clinical and non-clinical needs to achieve health goals designed to improve functional status, health status, or prevent decline
• 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, social and Community Supports’ needs
• Visit patients in their homes or where they seek care, or prefer to access services in their community using and completing patient interviews on health condition knowledge and motivation to engage in self-management
• 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
• Work with ECM Clinical Nursing Specialist to monitor medication adherence to include medication management and reconciliation periodically for changes, especially at time of care transitions
• Perform population management tasks such as appointment scheduling, prevention and screening recalls, monitoring referrals, patient portal callbacks and responding to telephone messages
• Ensure proper, concise and accurate documentation of conversations held with patients and appropriate billing and coding are submitted
• Provide services in a culturally-appropriate and sensitive manner exhibiting the highest respect of all people and the strengths of their background, life experience and motivations
• Manage caseloads according to mandated program requirements to ensure compliance with timely completion of care planning, follow-up activities, documentation and submission timeframes
• Serve as liaison between health plan(s), program and community
• Participate in health plan ECM-related audits

Minimum

• Bachelor’s degree in social work, psychology, counseling, behavioral science, or other related field
• Two years’ experience in a healthcare setting, preferably providing direct patient care, or with duties involving patient education and advocacy.
• Bilingual English/Spanish
• Valid CA driver’s license and vehicle insurance, reliable transportation
• Minimum one year lead or supervisory experience

Preferred

• Master’s degree in Social Work (MSW) or other related field
• Experience working with patients with a serious mental illness and/or substance use disorder

Required Skills/Knowledge/Abilities

• Strong interpersonal relationship, leadership, and communication skills
• Ability and willingness to work flexible hours, including evenings and weekends
• Excellent verbal and written skills necessary for communication with patients/clients, clinicians and other staff
• Excellent customer service skills and commitment to providing the highest level of customer satisfaction
• Visual acuity and hearing ability to drive safely

Pay Range

• $27.00 -$29.00 hourly