Care Manager - ECM, SF

Clear Destination Inc.; San Francisco, Northern (CA, KY); Hybrid; USD 95,000 - 120,000; Full time

Job summary

HealthRIGHT 360 in San Francisco seeks a Lead Care Manager for the Enhanced Care Management (ECM) program. You will maintain a caseload and connect clients with health benefits, behavioral health, housing, and community resources, coordinating care across a multidisciplinary team.

This field-based role requires travel to client homes and service sites, strong communication, trauma-informed approaches, and the ability to document progress within 24 hours.

Qualifications

• High school diploma or equivalent required.
• A minimum of two years’ experience in the human service field and/or demonstrated expertise in substance use treatment, relapse prevention, and recovery preferred.
• Current First Aid and CPR certification.
• Valid California driver’s license and access to registered and insured transportation.
• Experience working with clients experiencing acute withdrawal from substances.
• Experience delivering evidence-based practices preferred.
• Knowledge of and experience with providing trauma-informed services.

Responsibilities

• Maintain a caseload and link clients to appropriate services.
• Engage with ECM members across health, housing, and social supports.
• Travel frequently; field-based work.
• Complete progress notes and documentation within required timelines.
• Collaborate with multidisciplinary care team to coordinate care.

Skills

Care coordination

Case management

Communication

Travelling field-based

Education

High school diploma or equivalent

Job description

JOB SUMMARY

HealthRIGHT 360, a nonprofit organization and a family of programs, is committed to providing accessible and comprehensive healthcare services to vulnerable populations. Our mission is to tackle systemic barriers to healthcare and promote health equity for all. We offer a wide range of services, including mental health care, residential and outpatient substance use treatment, and primary health services. Additionally, we provide transitional support for individuals re-entering the community after involvement in the criminal justice system. By integrating physical and behavioral health, we empower individuals to overcome challenges by addressing social determinants of health, fostering resilience, and facilitating recovery.

CalAIM

CalAIM is an initiative of the Department of Health Care Services (DHCS) to improve the quality of life and health outcomes of Medi-Cal recipients by implementing delivery system, program, and payment reforms across the Medi-Cal program. A key feature of CalAIM is the statewide introduction of an Enhanced Care Management (ECM) benefit and a menu of Community Supports, which, at the option of a Managed Care Plan (MCP), publicly funded health insurance plans for low-income citizens, can address the clinical and non-clinical needs of Populations of Focus with the most complex medical and social needs.

Key Responsibilities

The Lead Care Manager (LCM) at the ECM program will maintain a caseload of members served under the Managed Care Plan (MCP) providing care by linking the client with appropriate services to address specific needs such as: health benefits, mental health, substance use disorder, physical health, employment, family and children services, Justice-Involved concerns, housing, community resources, outpatient substance use disorder services, and aftercare. This role will take part in Enhanced Case Management (ECM) in partnership with local Managed Care Plans, including San Francisco Health Plan, Anthem, Kaiser and the Integrated Care Clinic, as well as coordinate with providers to provide case management needs for the clinic’s patient population. The LCM is required to identify and engage with each member in the community, including the member’s home, service provider locations and other, various locations requiring outreach.

Client Care and Care Coordination Responsibilities

• The Care Manager will be responsible for organizing patient care activities, sharing information with those involved as part of the multi-disciplinary care team, and implementing activities identified in the Managed Care Plan.
• Identifying eligible people from within State Prisons, County Jails, hospitals, and other locations for enrollment into the MCP.
• Using multiple strategies for engagement, including direct communication with the member (and/or their advocates), such as in-person meetings where the member lives, seeking care or is accessible; mail, email, texts, and telephone; community and street-level outreach.
• Maintaining regular contact with all providers identified as part of the members’ care team, whose input is necessary for successful implementation of member goals and needs, including Justice Involved oversight.
• Ensuring care is continuous and integrated among all service providers and referring to and following up with primary care, physical and developmental health, mental health, SUD treatment, and necessary community-based and social services, including housing, as needed.
• Providing support to engage the member in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment.
• Responsible for engaging with a multi-disciplinary care team to identify gaps in the member’s care and ensure appropriate input is obtained to effectively coordinate all primary, behavioral, developmental, oral health, Community Supports.
• Assist the client with intake by completing assessments as required by the MCP.
• Monitors client's progress toward achieving Care management treatment plan goals and provides treatment plan input.
• Assess the client’s Care Manager needs and completes all Releases of information.
• Connects the client to benefits, healthcare services, employment, housing, community resources, outpatient substance use services, and other benefits/resources available to the client.
• Coordinates communication and external service linkage including assisting with scheduling appointments, communicating with probation, scheduling child visits, communicating with Family and Children Services, obtaining all court minute orders, providing appointment reminders for therapy and psychiatrists.
• Collaborate with clients and their families to support reintegration into the community.
• Collaborate with outside agencies to help clients obtain needed community resources (housing, sober livings, substance abuse recovery agencies, medical facilities, employment/education agencies, DPSS, DMV or other needed resources).

Clinical Documentation and Administrative Responsibilities

• Write and complete all progress notes within 24 hours of service delivery.
• Write clients’ progress letters and court reports.
• Complete all assigned Peer Reviews (Chart Audits) within a timely matter.
• Actively participate in assigned Group Supervision, agency, and team meetings.
• Participate in training opportunities and complete assigned training in a timely manner.

Training, Supervision and Quality Improvement Responsibilities

• Attend and actively participate in assigned case conferences to advocate a collaborative discussion for treatment needs.
• Actively participate in agency and team meetings.
• Participate in training opportunities.
• Communicates collaboratively with all members of the behavioral health team including medical, mental health, psychiatry, substance use disorder, and other staff.
• Complete all assigned training and Relias course assignments in a timely manner.

Field-Based Responsibilities

• This is a field-based position which requires frequent travel.
• A major component of the Lead Care Manager role involves meeting ECM members where they are in terms of their physical location and individual needs.
• The locations for client engagement and case management will be those most attainable and desirable for clients to receive services pertaining to their medical management, including substance use disorder, and plan of care. In addition, the Lead Care Manager will have access to an office space for case management activities, clinical supervision, and to attend all required training and meetings as needed.

And perform other duties as assigned.

Qualifications

Education, Certification, or Licensure

• High school diploma or equivalent required.
• A minimum of two years’ experience in the human service field and/or demonstrated expertise in substance use treatment, relapse prevention, and recovery preferred.
• Current First Aid and CPR certification.
• Valid California driver’s license and access to registered and insured transportation.
• Experience working with clients experiencing acute withdrawal from substances.
• Experience delivering evidence-based practices preferred.
• Experience providing trauma-informed services preferred.Knowledge of and experience with providing trauma-informed services.