The Exceptional Needs Care Coordinator: High Needs Case Manager (ENCC-CM)M) will provide focused assistance and support to high need Kaiser Permanente (KP) Medicaid and Charitable Program members. The ENCC CM enrolls special needs members into program who do not quality for other case management programs or who have failed or been discharged from those programs due to their inability/unwillingness to fully participate. The ENCC CM provides a variety of nursing interventions, primarily by telephone and electronically, but also in person when appropriate and as needed to establish a relationship with the member. The ENCC CM works closely in partnership with the Primary Care Medical Home team including Social Work, behavioral health providers and other nurse coordinators to identify members needs and develop a plan of care with patient participation. The ENCC CM ensures that services/interventions are well coordinated with no duplication of services. The ENCC CM works with non-KP providers for Mental Health, dental and other covered services. Coordination of internal and external services ensures appropriate access and communication. The ENCC CM is responsible for identification and remediation of barriers to care and access that can result in population disparities.

• Manage incoming referrals to ENCC Case Management; determine appropriateness to the program based on members willingness to accept CM services, ability to interact, and current caseload restrictions as appropriate.
• Triage findings from member assessments, identifying needs and issues and plan appropriate interventions. Determine Level of Care and frequency for contact. All ENCC CM patients require a minimum of one weekly telephone contact.
• With the member/family and appropriate KP staff and providers, develop a Case Management care plan that addresses short term and longer-term goals that are specific, attainable and measurable. As a Health-Connect-based Joint Care Plan becomes available, work collaboratively with the Primary Care Medical Home team to develop a all-inclusive plan to communicate all aspects of need and planned services. Work with PCP to ensure a clear medical treatment plan is documented.
• Provide case management and care coordination services for members with identified needs within the scope of the ENCC CM role by: Creatively using available and appropriate resources, including KP staff and providers, to support the unique needs of each member with special needs; Facilitating access to internal and external services; Monitoring the effectiveness of the interventions and modifying the care plan as needed with input from the member/family, internal and community contacts; Reinforcing the treatment plan through lifestyle, diet, and medication compliance including support for Opiate Therapy Plan compliance; Advising and coaching patients and families; Identify non-medical issues; environment, abuse and neglect, homelessness and hunger and other safety concerns and work with state agencies and KP providers to support and remedy where possible. Provide case management and oversight to members participating in the Patient Review and Coordination Program for WA Medicaid. Document interventions succinctly in HealthConnect and route to other providers and staff to ensure coordination of care and services. Add relevant intervention details to the Special Populations Registry.
• Strengthen and update the ENCC/SNCC program through: Education of staff/clinicians about ENCC/SNCC and the special needs of our low income population. Development and distribution of education, tools and materials for member coordination. Completion of an annual program review including related policies, desk procedures, and documentation tools. Act as a liaison between KP, other HMOs, and county and state organizations. Actively participates in Kaiser Permanente committees and workgroups and in county/state committee and functions.