Case Manager II

LifeLong Medical Care; Oakland (CA); On-site; USD 70,000 - 90,000; Full time

Job summary

LifeLong Medical Care is seeking a Case Manager II to join the primary care team. The CM II conducts outreach, psychosocial assessment, and care planning for patients with complex needs.

You will lead Enhanced Care Management implementation, coordinate referrals, and work across home, clinic, and community settings to support vulnerable populations. The role requires collaboration with care teams, advocacy for patients, and documentation in EHR/HMIS systems.

Qualifications

• High School diploma or GED required.
• 2+ years of progressively responsible health care or social work experience preferred.
• Bachelor’s degree in Social Work or related field preferred.

Responsibilities

• Outreach to patients at LifeLong locations and community sites.
• Develop and monitor patient-centered care plans with the team.
• Coordinate internal and external referrals and assist with applications.
• Maintain patient caseload per program/site standards.
• Document services in required data systems (EHR/HMIS).

Skills

Interpersonal skills

Verbal and written communication

Organizational skills

Problem-solving

Harm reduction

Teamwork

Flexibility

Advocacy

Education

High School diploma or GED

Bachelor’s Degree in Social Work or related field

Tools

Microsoft Office

Database systems

Job description

JOB SUMMARY: The Case Manager II (CM II), a key member of the primary care interdisciplinary team, provides services for patients with complex care needs. This position conducts patient outreach, engagement and psychosocial service assessment, assists in developing a patient-centered care plan, is the lead implementer of Enhanced Care Management (ECM) and coordinates service referrals and delivery. The Case Manager meets clients in home, clinic, or community as appropriate or required by the specific program/site. The CM II provides services to specific populations that have multiple complex health and social services needs and often provides care outside of a traditional health center setting, such as home visits, hospitals, supportive housing sites, encampments and shelters.This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.Essential Functions:Outreach, via telephone and in person at LifeLong, community and residential sites, to patients who meet case management program eligibility criteria or are prioritized by LifeLong for this serviceProactively meet and engage with patients to build effective relationships and assess strengths and needs through use of standard intake, screening tools, and health, and social services records reviewActively involve patients and caregivers, as appropriate, in designing and delivering services, including development of care plans, assuring alignment with patients’ values and expressed goals of careProvide and facilitate referrals for internal and external resources, and collaborate with the patient to complete required applications, forms, or releases of informationMaintain a patient caseload in accordance with LifeLong standards for the specific population served or site requirementsUtilize data registries and reports to manage caseload, meet program requirements, maintain grant deliverables, and promote high quality careProvide health education and training to patients, including but not limited to, harm reduction and disease risk-mitigation strategies that empower patients to manage their own health and wellness (e.g. overdose prevention, mitigating spread of communicable diseases)Assist patients with accessing and retaining public benefits and insurance (e.g. MediCal, SSI/SSDI, CalFresh, General Assistance, etc), and affordable/subsidized housingRespectfully and routinely communicate with patients, their care team members, external partners, and identified social supportsMaintain knowledge of patients’ medical/behavioral health treatment plans and facilitate utilization of services by providing resources such as accompaniment, transportation, in-home care, reminder calls etc.Participate in team meetings to coordinate care, support patient goals, and reduce barriers to accessing servicesAdvocate on behalf of patients to get their needs met and/or support patients to learn advocacy strategies for themselves.Provide case management services to patients with multiple complex acute or chronic medical or behavioral health conditions (e.g. HIV/AIDS, Hep C, congestive heart failure, severe diabetes, severe hypertension, psychosis, pregnancy, and homelessness)Provide general housing case management services that includes document readiness, housing problem solving, and assessments for Coordinated Entry SystemAssist with patient crisis intervention and de-escalationProvide and document billable services to eligible populations that result in revenue generation for LifeLongKeep current on community resources and social service supports to effectively serve the target populationDocument patient contacts/services in required data systems (EHR, HMIS etc.) according to LifeLong policySpecific activities may vary depending on the requirements of the program and funder.Promote diversity, equity, inclusion, and belonging in support of patients and staffRepresent LifeLong positively in the community and advocate on behalf of underserved populationsQualificationsCommitment to working directly with low-income persons from diverse backgrounds in a culturally responsive mannerCommitment to harm reduction, recovery, housing first, age-friendly and patient centered careStrong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change while maintaining a positive attitudeExcellent interpersonal, verbal, and written skillsAbility to prioritize tasks, work under pressure, and complete assignments in a timely mannerAbility to seek direction/approval on essential matters, yet work independently, using professional judgment and diplomacyWorks well in a team-oriented environmentConducts oneself in external settings in a way that reflects positively on your employerAbility to be creative, mature, proactive, and committed to continual learning and improvement in professional settingsJob RequirementsHigh School diploma or GEDAt least two (2) years of progressively responsible work or volunteer experience in a community-based health care or social work setting or at least one (1) year of experience as a Case Manager I or equivalent positionProficient skills using Microsoft Office applications like Word, Excel, and Outlook, as well as the ability to work in and/or manage databasesAccess to reliable transportation with current license and insuranceJob PreferencesBachelor’s Degree in Social Work, or another Health or Human Services fieldWork or lived experience in area(s) relevant to the population to be served: e.g. perinatal, homelessness, recovery, criminal justice, elder care, palliative and end-of-life care, or behavioral health