CalAIM Lead Case Manager

About us:

At Axis Senior Resource dba Axis Case Management, we are committed to enhancing the lives of individuals through compassionate and personalized care. We are a dedicated team that values a balanced work-life culture and a collaborative, supportive work environment. If you are passionate about making a difference in the lives of others and seeking opportunities for professional growth, this is the company for you!

Position Overview:

An Assisted Living Facility Transitions Case Manager (ALFT CM) is responsible for coordinating comprehensive, person centered care for individuals with complex health and social needs. The ALFT Case Manager works collaboratively with members, healthcare providers, social services, care homes, member support systems, and community organizations to ensure that individuals receive the necessary services and support for improved health outcomes. This role involves developing individualized care plans, monitoring patient progress, and advocating for resources to address medical, behavioral health and social needs.

• This Job Description is intended to convey information essential to understanding the scope of the position and is not intended to be an exhaustive list of responsibilities, duties or skills required.
• The responsibilities and expectations outlined herein may be subject to change at any time based on business needs, organizational priorities or management discretion.
• Employees may be required to perform other duties as assigned.

Key Responsibilities:

• Report directly to your supervisor.
• CREATE, UPDATE and REVIEW Care Plans (CP) (Reviews are to be done QUARTERLY OR AS NEEDED!)
• Reach out within 48 hours after being assigned a new member to the following: Member, PCP, Social Services (SS) in Skilled Nursing Facilities (SNF), Home Health (HH), Hospice, Social Worker (SW), Behavioral Health (BH), Responsible Party (RP), Caregiver (CG), Durable Power of Attorney (DPOA) or family.
• Review initial assessment (IA) within 48 hours of completion
• Create Care plan (CP) within 30 days of completed IA
• Review monthly Home Visit Monitoring (HVM) documentation to ensure needs are being met.
• Completed home visits must be reported to your supervisor daily via Blink, tracked via TripLog, and updated on the Monthly Service Tracker.
• Weekly contacts with members are mandatory.
• Communicate weekly with the member/their POA or RP AND the B&C or ALF
• Ensure members receive the following services at least once a year:

o Primary Care Physician (PCP) visit

o Lab work

o Annual Health Maintenance

o Vaccinations

o Vision

o Dentist

o Podiatrist

o Audiology

• Check and review Care Gaps regularly.
• Update 7 Core Services quarterly
• Determine eligibility for Social Security Income (SSI), State Disability Insurance (SSDI) and other state programs such as CalFresh, California Assistance Program for Immigrants (CAPI), Home and Community-Based Alternatives (HCBA), Adult Protect Services (APS), In-Home Support Services (IHSS), Behavioral Health (BH), and other applicable community based resources.
• Educate care homes (B&C/ALF) on reporting any changes in level of care, behavior or adverse medication reactions to the PCP, and to the ALF CM within 24 hours of any occurrence. This includes any hospital admissions and discharges.
• Report members needing Medication Reconciliation to the Assessment Nurse Coordinator (ANC).
• Review Medication Reconciliation with member after ANC completion.
• Responsible for notifying your supervisor of any changes to a member’s physical location status within 24 hours.
• Responsible for monitoring Medi-Cal benefit end dates and assisting members to renew their benefits to ensure there is not a loss in coverage.

Qualifications:

• STRONG Organizational Skills
• Excellent communication skills
• Committed to improving the lives of the elderly and underrepresented community members
• Must be competent with computer use and the ability to multi-task.
• Ability to act when there is a sense of urgency.
• Valid Drivers License
• Negative TB test
• Car Insurance

Key Attributes:

• Empathetic, patient-focused attitude with a passion for enhancing the well-being of individuals.
• Strong communication skills, both verbal and written, with the ability to engage effectively with patients, families and healthcare teams.
• Ability to work independently and as part of a collaborative team.
• Organized and detail-oriented with strong time-management skills.
• Professional conflict resolution skills and the ability to manage sensitive situations with care and respect.
• Ability to adapt to change.

Axis Senior Resource is an equal opportunity employer and values diversity. We do not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected status.

Pay: From $25.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Employee assistance program
• Employee discount
• Paid time off
• Professional development assistance
• Retirement plan
• Tuition reimbursement

Work Location: In person