Lead Care Manager 1

**On Lok** **Dedicated to The Care of Elders:** On Lok is a not-for-profit organization founded in the early 1970s by a group of citizens concerned about the plight of elders and the lack of long term options in the community. On Lok serves as the administrative arm of a group of five affiliated non-profit organizations. Its functions include research and development, human resources, fundraising and management information systems. We understand the importance of a system that works together. Your expertise, drive and passion can help us carry out our mission to improve lives and advance healthcare. **Join our team of leaders to begin a rewarding career!** **POSITION SUMMARY:** On Lok has been a pioneer in delivering programs and services for the elderly, including founding the Program of All-Inclusive Care for the Elderly (PACE). Through On Lok Enhanced Care Management (ECM), On Lok serves the following populations of focus: Adults aged 21 and over at risk of long term care institutionalization, Adult nursing facility residents transitioning to the community, Adults At Risk of Avoidable Hospital or ED Utilization, and at-risk seniors using coordinated care for OR care management and targeted interventions. The Lead Care Manager 1 will be responsible for coordinating health care resources,, providing education, and facilitating access to care for a panel of members . The Lead Care Manager 1 serves as a clinical advocate for members, an active interdisciplinary team member, and a liaison with other health and social service providers in the community. Staff in this role may work with members who have mental health conditions and substance use disorders. **Roles and Responsibilities:** **MEMBER PANEL MANAGEMENT & GROWTH** •Manages an assigned panel of member(s) and maintains complete privacy of member personal information and health information. •Conducts initial and routine home visits and assessments with members in order to develop, implement and update individual care plans and interventions, and makes appropriate timely referrals. •Performs a minimum weekly on-site visit to On Lok facilities, based on program or operational requirements. •Performs a minimum weekly in-person outreach visit based on member's care plan. •Outreaches to new candidates and actively participates in the growth of the program. **CARE PLAN DEVELOPMENT & MANAGEMENT** •Identifies comorbidities, hospitalizations, prescriptions, and other factors that could impact the member's health. •Identifies care plan goals and objectives by working in conjunction with members. •Oversees and supports the implementation of the member's care plan, connecting with member via phone or in-person to facilitate engagement, follow-up, and education/training to address the care plan. **RESOURCE & CARE COORDINATION** •Acts as a liaison and advocates between members, their physicians as appropriate, outside healthcare and social service agencies, and other community providers as needed. •Collaborates with the healthcare providers to help members meet their goals. •Connects members to other social services and supports they may need. **DEVELOP MEMBER RELATIONSHIPS (PATIENT ENGAGEMENT) & HEALTHCARE RECORDS MANAGEMENT** •Builds trust with members and their families and/or caregivers by providing support and care. •Communicates with members about their care plan and engages other care team partners in the discussion when necessary. •Accurately documents all member interactions, care plans, and relevant information in the electronic health record (EHR) system in a timely and compliant manner. •Generates member reports as needed. **ADDITIONAL OPERATIONAL RESPONSIBILITIES** •Participates in and contributes to required team meetings, aggregate report meetings, and trainings to support professional development and effective care coordination. •Other duties as assigned. **QUALIFICATIONS (knowledge, skills, abilities):** - Bachelor's Degree in Social Work, Behavioral Health, or Public H…