SUMMARY: The Enhanced Care Management (ECM) program is a funded through California Advancing and Innovating Medi-Cal (CalAIM), and is a program that coordinates care by utilizing a person-centered approach to maximizing individual’s health and life trajectory. The ECM Program is a new program that provides extra care and coordination services to certain MC patients with complete medical needs and chronic conditions.  All ECM members must be enrolled in a Managed Care program of either the Inland Empire Health Plan (IEHP), Molina Healthcare, or Health Net. CalAIM will improve Medi-Cal for people with complex needs and who are facing difficult life and health circumstances. It is focused on breaking down the traditional walls of health care – extending beyond hospitals and health care settings into communities. As a key part of CalAIM, Enhanced Care Management (ECM) is a new statewide Medi-Cal benefit available to select “Populations of Focus" that will address clinical and non-clinical needs of the highest-need enrollees through intensive coordination of health and health-related services. It will meet beneficiaries wherever they are – on the street, in a shelter, in their doctor's office, or at home. The program is designed to leverage existing community care management infrastructure and experience

DUTIES: The SCII is responsible for working effectively with and as part of the Step Up’s ECM 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 ECM team members, member families and other professionals including the designed PCP care team.

Direct Service and Support

• Manage and Coordinate care for a define caseload of ECM members with behavioral health needs as define in the Scope of Work ECM and within scope of practice.
• Participate in outreach and engagement efforts to enroll referred members in ECM.
• Utilize brief behavioral health therapeutic interventions as necessary to improve the member’s ability to manage their own mental health concerns and symptoms.
• Assist members with care coordination needs.
• Collaborate on Member care issues with other STEP UP’S ECM team participants in weekly systematic case reviews and ad hoc case reviews and consult with nurse care manger and or behavioral health providers before taking any action that is clinical in nature.
• 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.
• Assists with the coordination of medical and behavioral health access issues with Step Up’s FSP Program, PCP offices, specialists and ancillary services.
• Provide formal and informal training and support for ECM members on behavioral health conditions including evidence-based for treatments.
• Represent the Step Up’s ECM when requested by the Program Director or as needed for clinical support and direction.
• Participate in STEP UP’S ECM team meetings to share info update and inform care plan and care transition plan responsibilities.
• Model the highest ethical behavior in relationship with co-workers, supervisor, members, provider, and colleagues in the community and within Step Up’s ECM.
• Promote a collaborative and effective working environment with the STEP UP’S ECM by engaging in evidenced based communication strategies (such as Motivational Interviewing) when discussing responsibility/sharing of tasks, effective resolving conflict as they arise and collaborating on member case discussions.
• Build and maintain a positive working relationship with other community partners and providers including by not limited to communication via in-person, over the phone, and through digital means, such as email and fax.
• Model commitment to continuous quality improvement by engaging in quality improvement initiative and projects such as by identifying and assessing gaps and by identifying, developing and testing new practices for improving the outcomes of the ECM program.
• Participate in staff meetings, trainings committee meetings and other activities as needed or directly by the STEP UP’S ECM program.
• Any other duties as required to ensure ECM operations are successful.

Documentation and Data Collection

• Complete and become proficient in each provider’s Electronic Health Record to ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards.
• Maintain documentation for each contact as instructed and within the program timelines (weekly, monthly, quarterly).
• 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
• Ensure completion of the Complex Health Assessment (CHA) for all eligible ECM high-risk members within specified timeframe.
• Assimilate CHA information into the (SCP) Shared Care Plan/Health Action Plan (HAP).
• Communicate PHQ9 with member, approved family or caregiver and other members of the care team.

SKILLS: Highly skilled interpersonally, with excellent relationship skills including resolving conflict with co-workers. Knowledgeable and skilled in evidenced based communication such as Motivational Interviewing or similar empathy-based communication strategies. Able to sufficiently engage members and providers on the phone, including developing effective relationships that are phone based. Understanding of and sensitivity to multi- cultural communities. Deep understanding and knowledge of mental health and substance use conditions, including self-managed philosophies and practices. Awareness of the impact of unmitigated bias, and judgement on health; a commitment to addressing both. Bilingual (English/ Spanish) preferred. Must be able to work as a member of a highly autonomous team, executing job duties and making skillful decisions as an independent team. Must have skills to tolerate, manage and make effective use of a high level of ambiguity around new team models, new models of are, and new care management practices.

QUALIFICATIONS: Masters in Social Work or a Marriage and Family Therapist degree (MSW or MFT) and registered with the California BBS to obtain hours for licensure OR is a LMHP in California AND registered with the CA BBS for practice. 2) A valid California driver’s license and clean driving record. A reliable vehicle and valid automobile insurance is mandatory as automobile travel is required in the Inland Empire either by personal or company vehicle. Step Up will verify these requirements. 3) No findings on (DOJ) Department of Justice background check. MUST BE FULLY VACCINATED FOR COVID-19.

Experience: Minimum three (3) experience of performing or facilitating behavioral health services in a community clinic or health care delivery setting. Familiarity with Managed Care and discharge planning. Strong diagnostic skills and experience working with homeless and/or SMI populations.

SUPPLEMENTAL INFORMATION: Work with people experiencing homelessness whether on the streets, in shelters or other places of habitation or services, may present inherent challenges and difficulties such as: exposure to bed bugs or other infestations, unpleasant smells or odors, individuals who may have poor hygiene or unclean homes due to homelessness, mental health symptoms, or poverty. Additionally, in working with our members, employees may encounter instances of profanity, sexually explicit or derogatory language, or verbal or physical expressions of anger and trauma. Very rarely do these situations ever escalate to physical contact, and negative or derogatory communication patterns can often be negotiated successfully. All direct care staff are provided adequate training to develop skills to deescalate crisis situations that may arise and Step Up has established procedural safeguards for all employees to mitigate (but not eliminate) these inherent risks of employment.

PHYSICAL REQUIREMENTS: While performing the duties of this job, the employee is regularly required to sit; use hands and fingers; handle or feel; reach with hands and arms; talk; and hear. The employee is frequently required to walk, balance, stoop, kneel, and/or crouch. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Keyboard data entry required.

Step Up utilizes the principles of trauma-informed care and mental health recovery. These principles inform our Core Values of Hope, Wellness, Voice and Choice, Respect, and Collaborative Relationships. As representatives of Step Up, employees agree to adhere to these values in their interactions with members, colleagues, supervisors, and associated community members.

STEP UP CORE VALUES

HOPE – We believe all people have the capacity for positive growth and change. We use hope to inspire and motivate ourselves, our members, our colleagues, and our community.

WELLNESS – We believe in promoting a culture that supports healthy and fulfilling lives. We use a supportive environment to foster well-being for ourselves, our members, our colleagues, and our community.

VOICE AND CHOICE – We believe in the right to choose and be heard. We use voice and choice to create meaningful outcomes and empowerment for ourselves, our members, our colleagues, and our community.

RESPECT – We believe in promoting interactions that are non-judgmental, transparent. We use respect to guide all of our words and actions with ourselves, our members, our colleagues, and our community.

COLLABORATIVE RELATIONSHIPS – We believe in forming partnerships to share resources, knowledge, and experiences. We use collaborative relationships to strengthen accomplishments for ourselves, our members, our colleagues, and our community.

Step Up provides equal employment opportunities without regard to age, ancestry, color, creed, mental or physical disability, marital status, medical condition, national origin, race, religion, sex, sexual orientation, veteran status, or any other consideration made unlawful by federal, state, or local laws.

STEP UP IS AN EQUAL OPPORTUNITY EMPLOYER

Job Type: Full-time

Pay: $62,400.00 per year

Benefits:

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

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

COVID-19 considerations:
Must be fully vaccinated for Covid-19.

Application Question(s):

• Why are you interested in working for our organization?

Education:

• Master's (Preferred)

License/Certification:

• Driver's License (Required)
• Mental Health Professional Certification (Preferred)

Work Location: One location

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