Nurse Care Coordinator III ECM

Job DescriptionSUMMARY : Enhanced Care management (ECM) is a funded through California Advancing and Innovating Medi- Cal (CalAIM), and are programs that coordinate care by utilizing a person-centered approach to maximizing individual's health and life trajectory. ECM services are medically appropriate and cost-effective alternatives to services covered under the state plan. All potential ECM members must be enrolled in a Managed Care program of either Inland Empire Health Plan (IEHP, Molina Healthcare or Health Net). Step Up is a contracted provider of ECM services and will refer qualified members directly to Step Up's ECM Programs. Step Up will begin outreach and engagement to promote the services, enroll the members in the ECM , and provide services intended to improve their social and physical determinants of health. Members remain in the ECM programs until they no longer need or want the services. ECM services consist of a care team providing in-person care management and care coordination that aims to ensure services are available from Managed Care providers for members who are frequent utilizers of health services and individuals experiencing homelessness. The program is designed to leverage existing community care management, sustaining, housing transition, navigation, infrastructure, and experience. DUTIES : The following reflects essential functions for this job but does not restrict other tasks, which may be assigned: The Nurse Care Coordinator III is responsible for working effectively with and as part of the Step Up's HHP interdisciplinary team to provide high quality, effective care management to ECM members. Care management is broadly defined and can include: outreach and engagement to members, engaging members in skilled therapeutic interactions to promote health behaviors, other behavioral health interventions within scope, coordination of care, resource linkages, working with other professionals and organizations in the community to ensure quality of care for members, seamless transition of care, and facilitating the right care and the right time for the members. This position works collaboratively with Step Up's HHP team members, member families and other professionals including the designed PCP care team. Direct Service and Support: 1. Manage and Coordinate care for a define caseload of HHP members with complex medical needs (tier 1) as define in the Scope of Work ECM and within scope of practice. 2. Participate in outreach and engagement efforts to enroll referred members in HHP. 3. Utilize brief interventions as necessary to improve the member's ability to manage their own health. 4. Assist members with care coordination needs including but not limited to the following: a) Ensure completion of the Complex Health Assessment (CHA) for all eligible ECM members within specified timeframe. b) Conduct comprehensive holistic assessment according to the scope of the RN license. c) Assimilate CHA information into the SCP Shared Care Plan/Health Action Plan HAP. d) Communicate SCP/HAP with member, approved family or caregiver and other members of the care team. 5. Engage with members both in person in a field-based setting and on the phone in a manner that utilizes evidence-based approaches, such as MI, that promote collaboration between the member and his or her health. 6. Assists with the coordination of medical and behavioral health access issues with Step Up's FSP Program, PCP offices, specialists and ancillary services. 7. Provide formal and informal training and support for ECM members on medical conditions including treatments and evidence-based for treatment. Documentation and Data Collection 1. Complete and become proficient in each Healthcare provider's Electronic Health Record to ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards. 2. Maintain documentation for each contact as instructed and within the program timelines (weekly, monthly, quarterly). 3. Ensure the privacy and security of the PHI as outlined in Step Up's policies and procedures relating to HIPAA complain including attending annual compliance training. 4. Represent Step Up's ECM as the lead member when requested by the Director or as needed for clinical support and direction. 5. Participate and lead care transition plan responsibilities. 6. Collaborate on Member care issues with other Step Up ECM team participants in weekly systematic case reviews and ad hoc case reviews and consult with nurse care manger and or behavioral health care manger before taking any action that is clinical in nature. 7. Model the highest ethical behavior in relationship with co-workers, supervisor, members, provider, and colleagues in the community and within Step Up's ECM. 8. Promote a collaborative and effective working environment with Step Up's ECM by engaging in evidenced based communication strategies (such as Motivational Interviewing) when discussing responsibility/sharing of tasks, effective res