Case Manager IV

LifeLong Medical Care; Berkeley (CA); On-site; USD 85,000 - 110,000; Full time

Job summary

LifeLong Medical Care is seeking a Case Manager IV to support patients with multiple complex care needs. You will conduct outreach, assess psychosocial needs, and help develop patient-centered care plans across home, clinic, and community settings.

You will lead Enhanced Care Management implementation, coordinate referrals, and provide housing navigation, with a focus on coordinating care for individuals with HIV/AIDS, chronic conditions, homelessness, and social needs.

Qualifications

• Commitment to working directly with low-income persons from diverse backgrounds in a culturally responsive manner.
• Commitment to harm reduction, housing first, and patient-centered care.
• Strong organizational and problem-solving skills with flexibility to adapt to change.

Responsibilities

• Outreach to patients via telephone and in person at LifeLong sites and communities to assess eligibility and engage care.
• Develop and maintain patient-centered care plans with input from patients and caregivers.
• Coordinate referrals to internal and external resources and assist with applications and releases of information.
• Maintain caseloads per LifeLong standards and use data registries to manage care and meet program requirements.
• Provide health education, harm reduction, and disease risk mitigation strategies to empower patient self-management.
• Lead housing navigation and connect patients to Coordinated Entry resources and housing supports.

Skills

Outreach

Care management

Care coordination

Data management

Harm reduction

Communication

Education

Bachelor’s degree in Social Work or related field

CADC certification or CA registration

Tools

Microsoft Office

EHR/HMIS systems

Data analysis tools

Job description

JOB SUMMARY: The Case Manager IV (CM IV), 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 IV 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. In addition they provide comprehensive housing navigation support to clients. The Case Manager IV is distinguished by their role in relation to other case managers on the team and program operation including providing case manager onboarding and training, using data to support caseload management and quality assurance, and involvement in quality improvement and other projects.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 FunctionsOutreach, 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), and affordable/subsidized housingRespectfully 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 reducing barriers to accessing servicesProvide 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 SystemAssess patients to identify cognitive and/or behavioral health needs and provide brief interventions and short-term support using standardized tools and effective approaches for patient careCo-facilitate patient groupsProvide intensive case management to a caseload size in accordance with site or program standards focusing on a subset of the highest acuity patientsProvide specialized housing navigation services to patients who are matched to a housing resource through Coordinated Entry SystemLead crisis intervention response, de-escalation procedures, notification of the local mental health department and/or crisis response team, and follow-up careProvide and document billable services to eligible populations that result in revenue generation for LifeLongDevelop and maintain onboarding documentation pertinent to the Case Manager roleProvide training and onboarding support to new Case Managers according to program policy and procedure and under supervisor’s guidance and oversightProvide ongoing technical assistance and subject matter expertise through consultation and case conferencingCoordinate special projects assigned by site or program LeadershipAssist with triaging caseloads using data tools to identify patients and prioritize outreach, screenings, and follow up activitiesMentor and coach Case Managers, Interns, Apprentices, and VolunteersAssist in implementation of quality improvement and quality assurance effortsAssist in development and implementation of new workflows pertinent to the Case Manager roleThe CM IV is not a management position and is not responsible for supervisorial tasksAdvocate on behalf of patients to get their needs met and/or support patients to learn advocacy strategies for themselves.Keep 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 three (3) 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 either a Case Manager II or Case Manager III or equivalent position or registration or certification as a Certified Alcohol and Drug Counselor by one of the two certifying bodies in CaliforniaProficient 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 insuranceManage and analyze data for patient management and quality improvementStrong track record of meeting program requirements including productivity and documentation timelinessExperience training, coaching and mentoringProject management experienceStrong problem-solving skillsJob PreferencesBachelor’s Degree in Social Work, Health or Human Services fieldLived experience of homelessness, incarceration, foster care, mental health services, substance use services or addiction, or as a close family member of someone who has this experience