Lead ECM Care Manager — Multidisciplinary Care Coordinator

Bayview Hunters Point Foundation for Community Imp; San Francisco (CA); On-site; USD 90,000 - 130,000; Full time

Job summary

Bayview Hunters Point Foundation in San Francisco, CA seeks a Lead Care Manager for the Enhanced Care Management program. You will coordinate care, assess needs, and guide members through health and social services, working with a multidisciplinary team in a fast-paced environment.

The role emphasizes evidence-based practices, documentation in EHR, and collaboration with external partners, with a focus on high-need populations and ensuring compliant billing and reporting.

Qualifications

• Bachelor’s degree in Nursing, Social Work, Public Health, or related field required.
• 3–5 years of case management experience.
• RN/LCSW licensure preferred; CCM/ACM desirable.

Responsibilities

• Coordinate care across healthcare providers, social services, and caregivers.
• Conduct comprehensive health and psychosocial assessments.
• Develop and monitor individualized care plans addressing physical health, mental health, SUD, and other needs.
• Provide mental health promotion, crisis intervention, and connection to community resources.
• Ensure accurate documentation in EHR and billing systems.
• Complete monthly program reporting and ensure compliance with funding and regulatory requirements.

Skills

Care management

Client coordination

Team mentorship

Communication

Problem-solving

Data reporting

Education

Bachelor’s degree in Nursing, Social Work, Public Health, or related field

Master’s degree preferred

Tools

Case management software

EHR (Electronic Health Records)

Data reporting tools

Job description

Description

Position Overview:

The Lead Care Manager (LCM) is responsible for providing comprehensive case management to all populations of focus enrolled in the Enhanced Care Management (ECM) program at Bayview Hunters Point Foundation. The LCM facilitates access to and understanding of services and programs, helping members navigate the health and social services system to improve overall health and well-being. The ideal candidate is an energetic self-starter who works collaboratively within a multidisciplinary team and engages effectively with external partners and service providers.

Duties & Responsibilities:

• Serve as the primary contact for clients, coordinating care and communication with healthcare providers, social services, and caregivers.
• Conduct comprehensive health and psychosocial assessments to develop individualized, member-centered care plans.
• Oversee client goal setting and care plan development, ensuring plans address physical health, mental health, SUD, and other needs.
• Implement and monitor member care plans, educating clients and addressing barriers to care.
• Provide mental health promotion, social work services, crisis intervention, and connection to community resources.
• Assist clients in navigating health services, including arranging transportation and appointment scheduling.
• Ensure accurate and timely documentation of all services provided in accordance with Medi-Cal and Medicare billing requirements.
• Maintain up-to-date patient health records in the Electronic Health Record (EHR) and other business systems.
• Complete monthly reporting to ensure program compliance with funding and regulatory requirements.
• Monitor and adhere to billing procedures, ensuring alignment with state and federal regulations.
• Conduct outreach and engagement activities to connect with eligible members and log activity in the EHR system.
• Provide clinical guidance in implementing evidence-based practices, such as Motivational Interviewing and Trauma-Informed Care principles.
• Perform administrative tasks using HIPAA-compliant systems for remote work.
• Respect patient confidentiality and uphold HIPAA compliance.
• Attending training sessions, actively contributing to team development, and maintaining strong relationships with internal and external partners.
• Utilize video conferencing tools frequently for remote collaboration.
• Other duties as assigned.

Requirements

Preferred Qualifications:

• Education: Bachelor’s degree in Nursing, Social Work, Public Health, or a related field required. (Master’s degree preferred.)
• Experience: Minimum 3-5 years of case management experience. Experience in enhanced care management, healthcare, or social services is preferred.
• Licensure/Certification: Licensure as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or other relevant licensure preferred. Case management certifications (CCM, ACM) are desirable.
• Leadership Skills: Strong leadership, communication, and problem-solving skills, with the ability to manage and mentor a team effectively.
• Knowledge: In-depth understanding of care coordination, chronic disease management, behavioral health, social determinants of health, and community resources.
• Technical Skills: Proficiency in case management software, electronic health records (EHR), and data reporting tools.
• Preferred Qualifications: Experience working with high-need populations, including those with chronic illnesses, mental health conditions, homelessness, and substance use disorders.

Physical & Additional Requirements:

• Mandated court reporting
• Regular and reliable job attendance.
• Effective verbal and written communication skills.
• Proficiency in computer skills, including knowledge of Microsoft Office, Avatar, internet browsers, etc.
• Exhibit respect and understanding of others to maintain professional relationships.
• Independent judgement in evaluation options to make sound decisions.
• Ability to work effectively in an open office environment surrounded by moderate noise and distractions.
• Frequently required to sit; occasionally walk and stand; travel from the building to other sites.
• Specific vision abilities required by this job include close vision, distance vision, depth perception, and the ability to adjust focus.
• The employee must be able to meet deadlines with time constraints.
• May be asked to occasionally work irregular or extended hours while performing job duties.
• Valid California’s Driver’s License (if duties require).
• Able to meet required state, federal, local and BVHP standards.
• Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.
• At least two COVID-19 vaccinations (preferred).

As part of our commitment to maintaining a secure environment, all candidates selected for this position will be subject to a comprehensive background check clearance. This clearance is a standard part of our employment process and is conducted in accordance with applicable laws and regulations.

Work Location:

Onsite and Field-Based in San Francisco, CA 94124