Case Manager II (5652)

Lifelong Medical Care; El Cerrito, Oakland (CA, CA); On-site; USD 76,220,000 - 88,542,000; Full time

Job summary

LifeLong Medical Care seeks a Case Manager II to support patients with complex needs. You will conduct outreach, assess psychosocial needs, and lead Enhanced Care Management implementation. Services occur in home, clinic, or community settings to diverse populations including housing sites.

You will build relationships, develop care plans, coordinate referrals, and advocate for access to housing and benefits, while maintaining caseloads and documenting in EHR/HMIS systems.

Qualifications

• Commitment to working with low-income persons in a culturally responsive manner.
• Commitment to harm reduction, housing first, and patient-centered care.
• Strong organizational, administrative and problem-solving skills.

Responsibilities

• Outreach to patients in LifeLong and community sites to assess eligibility.
• Engage patients to build relationships and assess needs using intake tools.
• Develop care plans aligned with patient values and goals of care.
• Provide referrals for internal/external resources and help with forms.
• Maintain a patient caseload per LifeLong standards and program rules.
• Use data registries/reports to manage caseload and meet grant goals.
• Provide health education including harm reduction and disease prevention.
• Assist with access to benefits and housing options for patients.
• Communicate with care team and social supports to coordinate care.
• Document services in EHR/HMIS and other required systems.

Skills

Outreach

Patient engagement

Care coordination

Case management

Harm reduction

Advocacy

Education

High School diploma or GED

Bachelor’s in Social Work or related field

Tools

Microsoft Office

HMIS / EHR systems

Job description

Job Details

Job Location: Supportive Housing Program Idaho - El Cerrito, CA 94804

Position Type: Full Time

Salary Range: $26.60 - $30.84 Hourly

Job Shift: Day

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.

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.

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 service
• Proactively 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 review
• Actively 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 care
• Provide and facilitate referrals for internal and external resources, and collaborate with the patient to complete required applications, forms, or releases of information
• Maintain a patient caseload in accordance with LifeLong standards for the specific population served or site requirements
• Utilize data registries and reports to manage caseload, meet program requirements, maintain grant deliverables, and promote high quality care
• Provide 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 housing
• Respectfully and routinely communicate with patients, their care team members, external partners, and identified social supports
• Maintain 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 services
• Advocate 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 System
• Assist with patient crisis intervention and de-escalation
• Provide and document billable services to eligible populations that result in revenue generation for LifeLong
• Keep current on community resources and social service supports to effectively serve the target population
• Document patient contacts/services in required data systems (EHR, HMIS etc.) according to LifeLong policy
• Specific activities may vary depending on the requirements of the program and funder.
• Promote diversity, equity, inclusion, and belonging in support of patients and staff
• Represent LifeLong positively in the community and advocate on behalf of underserved populations

Qualifications

• Commitment to working directly with low-income persons from diverse backgrounds in a culturally responsive manner
• Commitment to harm reduction, recovery, housing first, age-friendly and patient centered care
• Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change while maintaining a positive attitude
• Excellent interpersonal, verbal, and written skills
• Ability to prioritize tasks, work under pressure, and complete assignments in a timely manner
• Ability to seek direction/approval on essential matters, yet work independently, using professional judgment and diplomacy
• Works well in a team-oriented environment
• Conducts oneself in external settings in a way that reflects positively on your employer
• Ability to be creative, mature, proactive, and committed to continual learning and improvement in professional settings

Job Requirements

• High School diploma or GED
• At 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 position
• Proficient skills using Microsoft Office applications like Word, Excel, and Outlook, as well as the ability to work in and/or manage databases
• Access to reliable transportation with current license and insurance

Job Preferences

• Bachelor’s Degree in Social Work, or another Health or Human Services field
• Work 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