ECM Lead Care Manager - Martin Luther King Community Healthcare, Los Angeles, CA - Los Angeles, CA
(2023-09)
- Manage 50 patient caseloads effectively, ensuring timely follow-up and appropriate interventions.
- Work with CalAIM populations of focus (people experiencing homelessness, adults with SMI/SUD, adults transitioning from incarceration, adults with complex medical needs).
- ILOS billing for LA Care and HealthNet
- Home visits for in person outreach
- Educate patients on self-care strategies, promoting independence and empowering them to manage their health conditions.
- Monitor progress towards patient goals, adjusting care plans as needed to achieve desired results.
- Improve communication among healthcare providers, streamlining the coordination of services for patients.
- Facilitate appointments and transportation
- Reduce hospital readmission rates by coordinating effective post-discharge care plans.
- Facilitate multi-disciplinary team meetings to ensure comprehensive care plans, enhancing patient outcomes.
- Conduct thorough assessments of patient needs to devise personalized care plans, addressing both health and social determinants.
- Collaborate with social services to connect patients with resources for housing, nutrition, and financial assistance, improving their overall wellbeing.
- Advocate for patients during care team discussions, ensuring their needs are prioritized.
Care Coordinator (Clinic) - Martin Luther King Community Healthcare, Los Angeles, CA - Los Angeles, CA
(2021-11 - 2023-09)
- Serve as experienced and motivated care coordinator for high volume (up to 20 patients/week) and fast-paced clinic.
- Coordinate continuity of patient care with patients and families/caregivers following hospital admission, discharge, Emergency Department visits, scheduling post discharge appointments.
- Coordinate continuity of patient care with external healthcare organizations and facilities.
- Support patient self-management of disease process and promotes behavioral modifications self-intervention.
- Insurance eligibility verification
- Appointment scheduling
- Assist patients with PCP and/or IPA/medical group change, transportation needs, and community resources.
- Act as main point of contact to help vulnerable individuals navigate complex healthcare system by operating as patient advocate and health systems navigator.
- Assist staff in daily patient interactions and support as needed.
- Support care managers to ensure Health Risk Assessments and Health Action Plans are conducted for patients enrolled in Diabetes Management.
- Organized special project workflow and coordinate between Los Angeles Department of Health Services (DHS)/Harbor-UCLA and surgical vascular team for dialysis patients in need of surgery.
Patient Support - Optum Care, Torrance, CA - Torrance, CA
(2017-11 - 2021-10)
- Managed multi-line phone system (on average 60 calls/day or 300 calls/week) and clerical support to several Optum Clinics in Los Angeles and South Bay Region.
- Utilize Optum systems to resolve patient needs such as scheduling/verifying appointments, authorizations, Rx refill requests, eligibility, updating demographics and sending messages to appropriate department and/or relaying messages from clinic to patient.
- Received incoming calls from contracted nursing facilities and hospitals personnel and paged physician on call.
- Provided services to internal and external individuals involving exchange of complex and sensitive information while acting as patient advocate.
- Reported unusual or urgent circumstances in patients' condition or environment immediately to nurse supervisor/Telehealth nurses as necessary.
- Trained and mentored new personnel hired to fulfill various roles.
