Case Manager II (Care Neighborhood)

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 Case 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. The position will require travel to sites throughout Alameda County.

The Care Neighborhood ECM program (Enhanced Care Management) is an innovative program to support and empower identified high risk-high needs patients to improve their health outcomes. The case manager will provide on-going care management for patient, and work with the multidisciplinary team (RN, PCP, MSWs, LCSWs) together to support and address the social determinants that impact health. Duties include outreach and engagement, development of the care plan, linkage of the patient with resources (food, housing, transport, financial) as well as linking the patient with care within the clinic. Much of this work will take place in various settings - medical office, specialists, hospitals and patients' homes.

This is a full time, benefit eligible position at our TRUST Health Center in Oakland.

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.

LifeLong Medical Care is a multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. LifeLong Medical Care is an equal opportunity employer. We strongly encourage applications from women, people of color, and bilingual and bicultural individuals and members of the lesbian, gay, bisexual, and transgender communities. Applicants shall not be discriminated against because of race, religion, sex, national origin, ethnicity, age, disability, political affiliation, sexual orientation, gender identity, color, marital status, medical condition, or any other protected classification.

Benefits

Compensation: $26.60 - $29.07/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including ten paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.

COVID-19 Vaccine Policy

In accordance with LifeLong Medical Care's commitment to provide and maintain a workplace that is free of known hazards, we have adopted a Mandatory COVID-19 Vaccine Policy to safeguard the health of our employees and their families; our patients and visitors; and the community at large from infectious diseases, that vaccinations may reduce. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Order of the California State Public Health Officer. Unless a reasonable medical or religious accommodation is approved, all employees must receive COVID-19 vaccinations.

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), 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 reducing 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

• 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, Health or Human Services field
• Lived 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